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Key Points

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  • Always consider aortic dissection in patients presenting with the acute onset of chest or thoracic back pain.

  • Initiate a rapid reduction in heart rate and blood pressure in all patients with a high clinical suspicion for aortic dissection before obtaining confirmatory diagnostic imaging.

  • Stanford type A (proximal) dissections typically require surgical intervention, whereas Stanford type B (distal) dissections are managed medically.

  • Complications of acute dissection include myocardial infarction, cardiac tamponade, aortic valve insufficiency, stroke, renal failure, paralysis, limb ischemia, and death.

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Introduction

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Acute aortic dissection is a rare but potentially life-threatening condition. Although the true incidence is unknown, it is estimated that there are between 6,000 and 10,000 new cases annually in the United States. Aortic dissection is more prevalent in men and in patients with advanced age, with approximately 75% occurring in patients between 40 and 70 years of age. Younger patients with aortic dissection usually have a history of an underlying connective tissue disease. Of note, about half of all aortic dissections in women under the age of 40 years occur in the third trimester or early postpartum period.

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Risk factors for acute aortic dissection include chronic hypertension, a bicuspid aortic value, coarctation of the aorta, or inherited connective tissue disorders such as Ehlers-Danlos and Marfan syndromes. Vascular inflammatory disorders such as giant cell arteritis or Takayasu arteritis are additional risk factors for dissection.

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Aortic dissection results from a tear in the intimal layer of the vessel wall. Common inciting factors include the chronic conditions listed previously, as well as illicit drug use or blunt thoracic trauma. High-pressure pulsatile blood will travel through this tear into the media layer of the aorta, thereby separating the intima from the adventitia. This creates a false lumen for aortic blood flow that can extend distally (antegrade), proximally (retrograde), or in both directions. Rarely, the false lumen will rupture through the adventitia, resulting in immediate hemodynamic collapse. The majority of aortic dissections originate in the ascending aorta (65%), the aortic arch (10%), or just distal to the ligamentum arteriosum (20%). The Stanford classification system divides aortic dissections clinically into types A and B. Type A dissections involve the ascending aorta, whereas type B dissections involve only the distal aorta (origin of the intimal tear is distal to the left subclavian artery) (Figure 17-1).

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Figure 17-1.

Stanford classification of aortic dissections A. Type A. B. Type B. (Reproduced with permission from Brunicardi FC, Andersen D, Billiar T, et al. Schwartz's Principles of Surgery. 8th ed. New York: McGraw-Hill Education, 2005.)

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Clinical Presentation

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History

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The classic presentation of an acute thoracic aortic dissection is that of a 55- to 65-year-old male with chronic hypertension who develops a sudden onset of severe sharp ...

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