Acute Aortic Dissection
- Author: John M Wiesenfarth, MD, FACEP, FAAEM; Chief Editor: Barry E Brenner, MD, PhD, FACEP more...
Aortic dissection is the most common catastrophe of the aorta, 2-3 times more common than rupture of the abdominal aorta. When left untreated, about 33% of patients die within the first 24 hours, and 50% die within 48 hours. The 2-week mortality rate approaches 75% in patients with undiagnosed ascending aortic dissection.
The establishment of the International Registry of Acute Aortic Dissection in 1996, which gathers information from 24 centers in 11 countries, has helped in the development of an understanding of the complexity of aortic dissection.
Dissections of the thoracic aorta have been classified anatomically by 2 different methods. The more commonly used system is the Stanford classification, which is based on involvement of the ascending aorta and simplifies the DeBakey classification.
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The Stanford classification divides dissections into 2 types, type A and type B. Type A involves the ascending aorta (DeBakey types I and II); type B does not (DeBakey type III).
This system helps to delineate treatment. Usually, type A dissections require surgery, while type B dissections may be managed medically under most conditions.
The DeBakey classification divides dissections into 3 types, as follows:
Type I involves the ascending aorta, aortic arch, and descending aorta
Type II is confined to the ascending aorta
Type III is confined to the descending aorta distal to the left subclavian artery
Type III dissections are further divided into IIIa and IIIb. Type IIIa refers to dissections that originate distal to the left subclavian artery but extend proximally and distally, mostly above the diaphragm.
Type IIIb refers to dissections that originate distal to the left subclavian artery, extend only distally, and may extend below the diaphragm.
Thoracic aortic dissections should be distinguished from aneurysms (ie, localized abnormal dilation of the aorta) and transections, which are caused most commonly by high-energy trauma.
Assure adequate breathing, maintain oxygenation, treat shock, and obtain useful historical information.
Establishing the diagnosis in the field is usually difficult or impossible, but certain salient features of aortic dissection may be observed. It is life threatening if not quickly recognized and treated.
Radio communication with the receiving hospital permits the medical control physician to direct care and select a capable destination hospital, while permitting the emergency department (ED) to mobilize appropriate resources.
In the rare event that the diagnosis can be made based on prehospital information, the physician directing prehospital care should request transport to a facility capable of operative treatment of an aortic dissection.
Emergency Department Care
The mortality rate of patients with aortic dissection is 1-2% per hour for the first 24-48 hours. Initial therapy should begin when the diagnosis is suspected. This includes 2 large-bore intravenous lines (IVs), oxygen, respiratory monitoring, and monitoring of cardiac rhythm, blood pressure, and urine output.
Clinically, the patient must be assessed frequently for hemodynamic compromise, mental status changes, neurologic or peripheral vascular changes, and development or progression of carotid, brachial, and femoral bruits.
Aggressive management of heart rate and blood pressure should be initiated.
Beta blockers should be given initially to reduce the rate of change of blood pressure (dP/dt) and the shear forces on the aortic wall.
The target heart rate should be 60-80 beats per minute.
The target systolic blood pressure should be 100-120 mm Hg.
End organ perfusion should be evaluated. Balancing the risks of dP/dt on the aortic wall versus the benefits of acceptable end organ perfusion may be a difficult clinical decision.
Retrograde cerebral perfusion may increase the protection of the central nervous system during the arrest period.
The mortality rate from aortic arch dissections is about 10-15%, with significant neurologic complications occurring in another 10% of patients. The mortality rate is influenced by the patient's clinical condition.
The American College of Radiology has established ACR Appropriateness Criteria for the diagnosis and treatment of suspected aortic dissection.
Type A dissections
Urgent surgical intervention is required in type A dissections. The area of the aorta with the intimal tear usually is resected and replaced with a Dacron graft. The operative mortality rate is usually less than 10%, and serious complications are rare with ascending aortic dissections.
The development of more impermeable grafts, such as woven Dacron, collagen-impregnated Hemashield (Meadox Medicals, Oakland, NJ), aortic grafts, and gel-coated Carbo-Seal Ascending Aortic Prothesis (Sulzer CarboMedics, Austin, Tex), has greatly enhanced the surgical repair of thoracic aortic dissections.
With the introduction of profound hypothermic circulatory arrest and retrograde cerebral perfusion, the morbidity and mortality rates associated with this highly invasive surgery have decreased.
Dissections involving the arch are more complicated than those involving only the ascending aorta, because the innominate, carotid, and subclavian vessels branch from the arch. Deep hypothermic arrest usually is required. If the arrest time is less than 45 minutes, the incidence of central nervous system complications is less than 10%.
Aortic stent grafting is a challenging technique. It may prove feasible and has offered good results in a small series of patients. It may be a reasonable alternative in high-risk patients in the near future.
Type B dissections
The definitive treatment for type B dissections is less clear. Uncomplicated distal dissections may be treated medically to control blood pressure. Distal dissections treated medically have a mortality rate that is the same as or lower than the mortality rate in patients who are treated surgically.
Surgery is reserved for distal dissections that are leaking, ruptured, or compromising blood flow to a vital organ.
Acute distal dissections in patients with Marfan syndrome usually are treated surgically.
Inability to control hypertension with medication is also an indication for surgery in patients with a distal thoracic aortic dissection.
Patients with a distal dissection are usually hypertensive, emphysematous, or older.
Long-term medical therapy involves a beta-adrenergic blocker combined with other antihypertensive medications. Avoid antihypertensives (eg, hydralazine, minoxidil) that produce a hyperdynamic response that would increase dP/dt (ie, alter the duration of P or T waves).
Survivors of surgical therapy also should receive beta-adrenergic blockers.
A series of patients with type B dissections demonstrated that aggressive use of distal perfusion, CSF drainage, and hypothermia with circulatory arrest improves early mortality and long-term survival rates.
Endovascular stenting remains an option for treatment of some type B dissections. Some studies recommend that patients with complicated acute type B dissections undergo endovascular stenting with the goal of covering the primary intimal tear.
Definitive treatment involves segmental resection of the dissection, with interposition of a synthetic graft.
When thoracic dissections are associated with aortic valvular disease, replace the defective valve. With combined reconstruction–valve replacement, the operative mortality rate is approximately 5%, with a late mortality rate of less than 10%.
Operative repair of the transverse aortic arch is technically difficult, with an operative mortality rate of 10% despite induction of hypothermic cardiocirculatory arrest.
Repair of the descending aorta is associated with a higher incidence of paraplegia than repair of other types of dissections because of interruption of segmental blood supply to the spinal cord.
The operative mortality rate is approximately 5%.
In a study by Mimoun et al of patients with Marfan syndrome who had acute aortic dissection, the patients were found to have a better event-free survival when there were no dissected portions of the aorta remaining after surgery.
A study by Rylski et al indicated that in patients with type A aortic dissection, aggressive hemiarch replacement is associated with a low mortality rate and a low incidence of reintervention. The study involved 534 patients with acute type A dissection who underwent hemiarch replacement. The investigators found that at 1-, 5-, and 10-year follow-up, the patient survival rate was 80%, 68%, and 51%, respectively. During the same follow-up period, no distal reintervention was required in 97%, 90%, and 85% of patients, respectively.
Once a thoracic dissection is suspected, consult a thoracic surgeon. Because many patients with this disorder have concomitant medical illness, consult the patient's primary care provider to expedite preoperative preparation. Early consultation is encouraged when ordering further imaging studies if the patient requires rapid operative intervention.
Consult a radiologist prior to obtaining aortography.
Patients with symptomatic dissection should undergo immediate repair, especially if it is leaking or expanding.
Symptomatic patients require admission to a center experienced in cardiopulmonary bypass and operative care.
Completely asymptomatic patients may have their repair performed electively but may require admission to expedite their evaluation or for preoperative stabilization of their condition.
Patients with chest pain should undergo serial echocardiograms (ECGs) and creatine kinase (CK) determinations if acute myocardial infarction (AMI) is indicated.
Follow-up examinations with radiologic studies are recommended at 3-month intervals for the first year and every 6 months for the next 2 years.
After this, follow up annually.
Symptomatic patients require care at a facility equipped to perform cardiopulmonary bypass with aortic and/or valvular repair.
Contact the receiving physician as soon as possible to transfer patients before their condition deteriorates.
Early airway management is indicated in the presence of hemoptysis or stridor.
If coronary insufficiency is suspected, nitrates may be used, but therapy with thrombolytic agents and aspirin should be avoided.
Patients should be monitored and accompanied by personnel capable of resuscitation.
If a prolonged ground transport time is anticipated, consider air transport.
Initial therapeutic goals include elimination of pain and reduction of systolic blood pressure to 100-120 mm Hg or to the lowest level commensurate with adequate vital organ (ie, cardiac, cerebral, renal) perfusion.
Whether systolic hypertension or pain is present, beta blockers are used to reduce arterial dP/dt.
To prevent exacerbations of tachycardia and hypertension, treat patients with IV morphine sulfate. This reduces the force of cardiac contraction and the rate of rise of the aortic pressure (dP/dt). It then retards the propagation of the dissection and delays rupture.
These agents are used to reduce arterial dP/dt. For acute reduction of arterial pressure, the potent vasodilator sodium nitroprusside is effective. To reduce dP/dt acutely, administer an IV beta blocker in incremental doses until a heart rate of 60-80 beats/min is attained.
When beta blockers are contraindicated, such as in second- or third-degree atrioventricular block, consider using calcium channel blockers. Sublingual nifedipine successfully treats refractory hypertension associated with aortic dissection.
Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and prevents exacerbations of tachycardia and hypertension.
Checking for dissection prior to the administration of thrombolytics in the patient presenting with chest pain and ECG changes
Multiple case reports describe patients who received thrombolytics and were found later to have a dissection. The diagnosis of aortic dissection can be subtle.
The diagnosis depends on clinical suspicion, with contributory findings on history, physical examination, and imaging studies.
Obtaining a chest radiograph prior to administering thrombolytics is considered prudent.
Checking blood pressures in both arms and listening for carotid bruits also can help to diagnose aortic dissection prior to administering thrombolytics. The entire clinical picture must be taken into account.
[Guideline] Jacobs JE, Latson Jr LA, Abbara S, Akers SR, Araoz PA, Cummings KW, et al. Acute Chest Pain — Suspected Aortic Dissection. ACR American College of Radiology. Available at http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/AcuteChestPainSuspectedAorticDissection.pdf. Accessed: October 9, 2014.
Chaikof EL, Mutrie C, Kasirajan K, Milner R, Chen EP, Veeraswamy RK, et al. Endovascular repair for diverse pathologies of the thoracic aorta: an initial decade of experience. J Am Coll Surg. 2009 May. 208(5):802-16; discussion 816-8. [Medline].
Mimoun L, Detaint D, Hamroun D, Arnoult F, Delorme G, Gautier M, et al. Dissection in Marfan syndrome: the importance of the descending aorta. Eur Heart J. 2011 Feb. 32(4):443-9. [Medline].
Rylski B, Milewski RK, Bavaria JE, Vallabhajosyula P, Moser W, Szeto WY, et al. Long-term results of aggressive hemiarch replacement in 534 patients with type A aortic dissection. J Thorac Cardiovasc Surg. 2014 Jul 19. [Medline].