Aortic dissection

Table of Contents

Risk factors

Mnemonic: ABCDE

  1. Aortic aneurysm
  2. Boys (male), Blood pressure (hypertension) and Bicuspid aortic valve
  3. Connective tissue disorders (Marfans, Ehlers-Danlos)
  4. Delivery and pregnancy
  5. Elderly (50-70 years) and Exercise (heavy weight lifting)

Pathophysiology

Intimal tear allows blood to enter between intima-media space creating a false lumen. Blood may propagate proximal or distal to tear.

Clinical features

  1. Asymptomatic
  2. Tearing chest pain radiating to back (interscapular)
  3. Pulse deficit and differential pressure in limbs
  4. Signs of end organ ischemia

Investigations

  1. ECG: rule out cardiac ischemia
  2. CXR: Widened mediastinum (>8 cm), tracheal shift
  3. CT angiogram (stable patients): gold standard (intimal dissection flap, double lumen, aortic dilation, contrast leak)
  4. Transesophageal echocardiography/TEE (unstable patients)

Classification and Management

aortic dissection types
“Aortic Dissection STANFORD and DE BAKEY” by iem-student.org is licensed under CC BY-NC-SA 2.0.
StanfordDeBakeyDescriptionFrequencyManagement
Mnemonic: BADMnemonic: A for A; B for B
A (Ascending aorta involved)IBoth (Ascending aorta and Descending aorta)60%Arch replacement +/- Aortic root repair
IIAscending aorta10-15%
B (Ascending aorta not involved)IIIDescending aorta25-30%a. Uncomplicated – Beta blocker IV with aim:
HR: 60-80 bpm
SBP: 100-120 mmHg
aabove diaphragmb. Complicated (rupture, ischemia, false lumen expansion, continuing pain) – Endovascular treatment (TEVAR)
bbelow diaphragm
If pregnancy:
a. <28/40 weeks – Aortic repair with fetus in utero
b. >32/40 weeks – Primary CS followed by aortic repair in same setting


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