Second, tte was useful for diagnosing circumferential type a aortic dissection, which could not be diagnosed with enhanced ct. Abdominal aortic aneurysm aaa primarily affects the population. Background retrograde type a aortic dissection has been deemed a rare complication after endovascular stent graft placement for type b dissection. An aortic dissection is an emergency with your aorta, which is the largest blood vessel in your body and the main artery that takes blood from your heart to the rest of your body during an.
Etiology, classification, and symptoms aortic dissection acute aortic dissection is defined as dissection occurring within 2 weeks of onset of pain 2. The most common risk factor for aortic dissection is poorly controlled hypertension 6575% risk with a history of hypertension 1, 5. Abdominal aortic dissection can present with abdominal pain radiating to the flank or back. Take home points for aortic dissection diagnosis and management.
An aortic aneurysm occurs when a weak spot in the wall of your aorta begins to bulge left. Early and midterm outcomes of thoracic endovascular aortic repair tevar for acute and chronic complicated type b aortic dissection. Although hormonal changes in the aortic wall have been theorized as potentially playing a role, an underlying genetic disorder associated with abnormalities of the aortic wall such as that present in familial taad, marfan syndrome, loeysdietz aneurysm. From april 2004 to march 2017, 310 patients underwent surgical repair for acute type a aortic dissection at our institution. The authors describe dissections that originate from the arch or extend proximally into the arch without the involvement of the ascending aorta which are not adequately accounted for in the stanford nor the debakey classification systems. For a deep dive into the worlds literature on ddimer for aortic dissection visit em cases journal jam 9. The following are key points to remember about this update on the diagnosis and management of acute aortic syndromes aas. Retrograde type a aortic dissection after endovascular stent. The stanford system is classified into two types types a and b based on involvement of the ascending aorta 4.
Acute aortic dissection type a aada is still an emergency operation with high morbidity and mortality. Type a lesions aortic dissection, axial views aortic dissection, sagittal views intramural hematoma type b lesions e f a,typeaaorticdissection,axial contrastenhancedcomputed tomographyctatthelevelofthe pulmonaryarterybifurcation starfalselumen. Remember the big pain pearls when taking a history. Type a dissections can progress proximally to cause pericardial effusion with tamponade, as well as acute aortic valve insufficiency. The study is obviously limited by its small sample size, its retrospective nature, and the inability to provide data on subsequent ca reinterventions. Retrograde type a aortic dissection after endovascular. Aortic dissection is a more common problem than is ruptured abdominal aortic aneurysm.
Aortic dissection is the surging of blood through a tear in the aortic intima with separation of the intima and media and creation of a false lumen channel. Chen md director thoracic aortic surgery division of cardiothoracic surgery emory university school of medicine atlanta, georgia the houston aortic symposium, february 23, 2017. Aortic dissections are formed by a tear in the intima layer of the aortic wall, producing a perfused false lumen within the media. Acute type a aortic dissection is associated with a mortality rate of 50% within the first 48 h if not surgically treated, 1 so early diagnosis and surgical treatment are important. Computed tomography angiography at admission showing stanford type b aortic dissection. For type a aortic dissection, the mortality rate remains high, with up to a 30% death rate after surgery. Predictors for late reoperation after surgical repair of. Results in separation of the aortic wall layers and subsequent formation of a true lumen tl and a false lumen fl with or without communication. Type a aortic dissection is an aortic dissection that initially occurs in the very first segment of an individuals aorta, the ascending aorta where blood is pushed in an upward direction. The diagnosis and management of aortic dissection the bmj. The dissection may occur anywhere along the aorta and extend proximally or distally into other arteries.
However, this lifethreatening event appears to be underrecognized and is worth being investigated further. The extent of the dissection process along the aorta defines the type. Ethnic disparities in outcomes of patients with complicated type b aortic dissection. During the early hours after type a aortic dissection, the mortality risk increases about 1% per hour. It occurs when blood enters the medial layer of the aortic wall through a tear or penetrating ulcer in the intima and tracks along the media, forming a second bloodfilled channel within the wall. Aortic dissection ad disruption of the medial layer provoked by intramural bleeding. The presence of acute cardiorespiratory failure, chest pain, stroke, acute chest pain, and aortic dissection were most predictive of higher hospital mortality among other complications. Aortic dissection an overview sciencedirect topics. Aortic dissection describes the condition when a separation has occurred in aortic wall intima, causing blood flow into a new false channel composed of the inner and outer layers of the media. Aortic valve repair in type a aortic dissection leone the. Biomedical intelligence published 25 august 2017 doi. Esc guidelines on aortic diseases european society of cardiology. Describe the ed management of a pt with aortic dissection. This compares to a 25% mortality when treated surgically.
Jan 29, 2018 the symptoms of an aortic dissection can be difficult to distinguish from those of other heart conditions, such as a heart attack chest pain and pain in the upper back are the most common. Aortic dissection is the retinal detachment of the torso on pocus. The stanford classification divides dissections by the most proximal involvement. The classification of aad follows two different systems. The timing and need for intervention surgicalendovascular differs for ascending type a and descending type b. The incidence of aortic dissection has been reported to be. Aortic dissection ad occurs when an injury to the innermost layer of the aorta allows blood to flow between the layers of the aortic wall, forcing the layers apart. Presented as a poster at the 2017 vascular annual meeting of the society for vascular surgery, san diego, calif, may 31. Management of patients with coronary artery malperfusion. With regard to the type of dissection, group 1 had 4 80% cases of classic type obvious intimal flap formation aortic dissection and 1 case of intramural haematoma type. Aortic valve repair in type a aortic dissection the role of valve sparing operations in patients with the acute type a aortic dissection aaad, is still matter of debate. What is the definitive management for each type of aortic dissection. Dissection most commonly occurs with a discrete intimal tear, but can occur without one.
Having an aneurysm increases the risk of rupture or an aortic dissection a tear in the lining of the aorta, shown in the image on the right. Jan 11, 2012 aortic dissection is caused by an intimal and medial tear in the aorta with propagation of a false lumen within the aortic media. A type a tear may extend along the upper part of the aorta and down toward the abdomen. Prevalence of type iii arch configuration in patients with. May 14, 2016 aortic dissection ad is one of the most challenging vascular diseases, with an inpatient mortality as high as 30 % 1 and 30day and 5year fatality rates of just over 50 % and 60 %, respectively. Aortic dissection is caused by an intimal and medial tear in the aorta with propagation of a false lumen within the aortic media. Acute type a aortic dissection aaad continues to be one of the most complex and lifethreatening pathology of the thoracic aorta and is still considered a challenge for cardiothoracic surgeons. Acute aortic dissection aad is an important emergency that should be identified promptly. Typically presents in men older than 50 years of age, with sudden onset of severe ripping or tearing substernal or interscapular pain.
A case of circumferential type a aortic dissection with. Two populationbased studies indicated incidences of 2. Pdf blood groups and acute aortic dissection type iii. May present with syncope, heartrenal failure, or mesenteric or limb ischaemia. In 2014, a special report was published in radiology 4 that recognized an uncommon form of aortic dissection. However, it isto the best of our knowledgethe largest study to investigate the optimal treatment regimen and outcome of ca malperfusion secondary to type a aortic dissection. Classification of aortic pathologies endovascular today. Dake md, in comprehensive vascular and endovascular surgery second edition, 2009. In addition to coronary and peripheral artery diseases, aortic diseases contribute to the wide spectrum of arterial diseases. Acute aortic dissection is defined as dissection occurring within 2 weeks of onset of pain. It has been classified in four types by the society for vascular surgery depending on the type of condition. We present a notable case of a 63yearold male who presented with a.
Atypical profile of aortic injury associated with blunt. For untreated acute dissection of the ascending aorta, the mortality rate is 12% per hour early after symptom onset. Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. Look for marphans, listen for an aortic regurgitation murmur and f eel for a. An intimal tear is the initiating condition, resulting in tracking of the blood in a dissection plane within. Types of aortic dissection the aortaa candy caneshaped blood vessel originating in the chest at the top of the heart and extending into the abdomenis the largest artery in the body. The suggestions herein are intended to facilitate clinical decision making in the management of thoracic aortic disease. In its natural evolution, without treatment, acute type a aortic dissection.
Guidelines for the management of thoracic aortic disease in 2017. Aortic valve repair in type a aortic dissection leone. Blood surges through the tear, causing the inner and middle layers of the aorta to separate dissect. If the type a dissection is circumferential, earlier repair is needed, because severe complications e. Aas encompass a constellation of lifethreatening medical conditions including classic acute aortic dissection aad, intramural hematoma, and penetrating atherosclerotic aortic ulcer. Mortality is still high despite advances in diagnostic and therapeutic modalities. The debakey classification was the first to be proposed, in 1965.
The intimal tear may be a primary event or secondary to hemorrhage within the media. The debakey system is classified into three types types i, ii, and iii according to. Aortic injury is a rare, but very critical, medical condition that requires urgent care with extraordinary caution. Acute aortic dissection complicating pregnancy is uncommon. It is part of the acute aortic syndromean umbrella term for aortic dissection, intramural haematoma, and symptomatic aortic ulcer table.
Presented as a poster at the 2017 vascular annual meeting of the society for vascular surgery, san diego, calif, may 31june 3, 2017. Aortic dissection ad is one of the most challenging vascular diseases, with an inpatient mortality as high as 30 % 1 and 30day and 5year fatality rates of just over 50 % and 60 %, respectively. An aortic dissection is a serious condition in which the inner layer of the aorta, the large blood vessel branching off the heart, tears. David procedure in acute type a dissection edward p. Of the 278 hospital survivors, 38 underwent late reoperation associated with aortic dissection during the followup period. Along with the debakey classification, the stanford classification is used to separate aortic dissections into those that need surgical repair, and those that usually require only medical management. Today marks the 4th anniversary of the em basic podcast. Acute aortic dissection ad is the most frequent and catastrophic manifestation of the socalled acute aortic syndrome which also includes intramural hematoma, penetrating aortic ulcer, and ruptured thoracic aortic aneurysm. In most cases, this is associated with a sudden onset of severe chest or back pain, often described as tearing in character. In aaad, the extension of aortic replacement and the management of the dissected aortic root continue to represent two aspects on which there is no convergence of opinions. Aortic surgery has the highest serious complication rates of any cardiac surgical procedures. Methods and results eleven of 443 patients developed retrograde type a aortic dissection during or after stent grafting for type b.
Endovascular stent graft placement has been used increasingly in the treatment of stanford type b aortic dissection since its safety and efficacy were reported at the end of the last century. Clinical features are often nonspecific, with no single sign or symptom able to positively diagnose acute aortic dissection. Management of acute aortic dissection and thoracic aortic rupture. If the bloodfilled channel ruptures through the outside aortic wall, aortic dissection is often fatal. Management of descending thoracic aorta diseases european. Tears in the intimal layer result in the propagation of dissection proximally or distally secondary to blood entering the intimamedia space. In this acute situation quick cannulation to the heartlung machine and systemic cooling is. Type b aortic dissections, treated medically, have an initial death rate of 10%. What is the definitive management for each type of aortic. It usually occurs during labor and delivery or in the early postpartum period.
However, the exact mechanism underlying this phenomenon is still unknown, and the onset of aortic dissections continues to be largely unpredictable in individuals with a normal aorta, i. Aortic dissection occurs when a tear occurs in the inner muscle wall lining of the aorta, allowing blood to split apart the muscle layers of the aortic wall symptoms of aortic dissection include a tearing or ripping pain in the chest, sweating, nausea, shortness of breath, weakness, or syncope. Diagnosis of ga was made for 760 patients ns taa, n311. If the aortic dissection occurs in the ascending aorta, the curved part of the aorta that extends upward from the heart, its called a type a aortic dissection. This is a very challenging disease to diagnose because patients have lots of different presentations that can make it difficult to diagnose. However, it isto the best of our knowledgethe largest study to investigate the optimal treatment regimen and outcome of. Subacute and chronic dissections occur between 2 and 6 weeks, and more than 6 weeks from the onset of pain, respectively. Types of aortic dissections university of michigan. There are two types of aortic dissection, type a and type b. Stanford which defines lesions as types a, on the ascending aorta, or b, on the descending aorta and debakey, which also accounts for the extension of the aortic dissection. The 687 patients surviving 30 days after presentation were followed for a. Aortic dissection symptoms, diagnosis and treatment bmj. The symptoms of an aortic dissection can be difficult to distinguish from those of other heart conditions, such as a heart attack chest pain and pain in the upper back are the most common. Circumferential type a aortic dissection is rare with an occurrence rate of approximately 2%, 2 and the severity is higher than that for other types of aortic dissection because the following main complications tend to.
The estimated incidence is 530 cases per million people per year. Jan 08, 2019 aortic dissection see the image below is defined as separation of the layers within the aortic wall. B,typebaortic dissection,axialcontrastenhanced ctatthelevelofthecarina starfalselumen. An aortic aneurysm is a general term for an enlargement dilation of the aorta to greater than 1. Ruptured aneurysm of the descending thoracic aorta. Other risk factors include age, male sex, smoking, preexisting aortic diseases or aortic valve disease, family history of aortic diseases, history of cardiac surgery, direct blunt trauma, and the use of intravenous drugs such as cocaine or amphetamines 1.
Endovascular approach to severe acute type b aortic dissection. Aortic dissection is the most common form of the acute aortic syndromes and a type of arterial dissection. Guidelines for the management of thoracic aortic disease. Aortic dissection is the most common acute emergency condition of the aorta, often resulting in the death of the patient. Thoracic aortic dissection is usually suspected clinically from the history and physical examination when a patient presents with severe, sharp, or tearing often migratory anterior chest pain in ascending aortic dissection or posterior chest or back pain arch or descending aortic dissection. Aortic dissection, axial views aortic dissection, sagittal views intramural hematoma type b lesions e f a,typeaaorticdissection,axial contrastenhancedcomputed tomographyctatthelevelofthe pulmonaryarterybifurcation starfalselumen. Aortic dissection is a relatively rare but highly lethal disease. Management of acute aortic dissection and thoracic aortic. Like other arteries, it carries oxygenrich blood from the heart to the rest of the body. Jul 27, 2015 today marks the 4th anniversary of the em basic podcast. Overall, for both types of aortic dissection, the 10year survival rate is more than 60%. This type of aortic dissection is more prevalent among the population than type b aortic dissection.
Medical management if not complicated type b complications include a decrease. A affects ascending aorta and arch accounts for 60% of aortic dissections. The goals of early management of aortic dissection are to control pain and limit the extension of the dissection using antiimpulse therapy, which typically involves administration of beta blockers and control of blood pressure. November 2017 classification of aortic pathologies. List 4 features of physical exam and 8 cxr findings suggestive of aortic dissection 7. Ethnic disparities in outcomes of patients with complicated.
While the sensitivity of pocus by ed physicians to detect an intimal flap is only 67%, the specificity has been shown to be 99100%. Aortic dissection symptoms, diagnosis and treatment. Two classifications are most commonly used for aortic dissection fig. What are the acute complications of aortic dissection. A recent study identified rupture as the cause of death in approximately onethird of affected patients admitted to the hospital, although the rate of nonfatal rupture may be considerably higher 1, 2. Aortic dissection treatment algorithm bmj best practice. Tear in the inner side of aorta causes blood to flow between layers of aorta. Genetic aortopathyga underlies thoracic aortic aneurysms taa in younger adults. To celebrate this occasion, we are going to do a screencast on aortic dissection. Stanford type b aortic dissection is one of the aortic catastrophes with a high mortality and morbidity that needs immediate or delayed treatment, either surgically or endovascularly. Stanford classification of aortic dissection radiology.
1135 799 1078 67 190 378 949 1194 1020 1377 1389 988 1257 45 654 610 653 1584 150 1051 1181 789 1547 970 1263 1021 1069 893 319 613 686 295 763 858 582 629 1236 588 495 120 324 252 1061 691 335 495 453 811