Aortic dissection

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

Stanford	DeBakey	Description	Frequency	Management
		Mnemonic: BAD		Mnemonic: A for A; B for B
A (Ascending aorta involved)	I	Both (Ascending aorta and Descending aorta)	60%	Arch replacement +/- Aortic root repair
	II	Ascending aorta	10-15%
B (Ascending aorta not involved)	III	Descending aorta	25-30%	a. Uncomplicated – Beta blocker IV with aim: HR: 60-80 bpm SBP: 100-120 mmHg
	a	above diaphragm		b. Complicated (rupture, ischemia, false lumen expansion, continuing pain) – Endovascular treatment (TEVAR)
	b	below diaphragm