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Aortic Dissection

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Aortic Dissection From: iradonline.org/images/aorta-layers.gif Types of Aortic Dissections Stanford Classification Type A = involves ascending aorta Type B = does ... – PowerPoint PPT presentation

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Title: Aortic Dissection


1
Aortic Dissection
2
Aortic Dissection
From iradonline.org/images/aorta-layers.gif
3
Types of Aortic Dissections
  • Stanford Classification
  • Type A involves ascending aorta
  • Type B does not involve ascending aorta
  • DeBakey Classification
  • Type I ascending and descending aorta
  • Type II ascending aorta only
  • Type III descending aorta only

4
From www.massgeneral.org/tac/patients/diseases.a
sp?ida_dissection
5
Aortic Dissection Risk Factors
  • Typically
  • Systemic Hypertension
  • Systemic Hypertension
  • Did I mention systemic hypertension?
  • Present in 60-90 of patients
  • In younger patients, must consider other
    factors
  • Bicuspid aortic valve (9 under 40 in one review)
  • Inflammatory disease (giant cell, syphilitic
    aortitis, RA, etc.)
  • Collagen Diseases (ED Syndrome, Marfans (50 in
    those under 40 in one review))
  • Preexisting aortic aneurysm
  • Coarctation
  • Others
  • CABG
  • Trauma
  • Iatrogenic (intravascular procedures)
  • Cocaine use (thought to be catecholamine
    mediated)

6
Clinical Manifestations/Findings
  • Acute onset of tearing chest pain, frequently
    radiating to the back
  • Syncope
  • Asymmetric BP in UE
  • Weak/absent peripheral pulses
  • Aortic Insufficiency/Heart Failure
  • MI
  • Renal failure
  • Paraplegia
  • Back Pain
  • Pericardial effusion

7
Many different presentations how to diagnose
clinically?
  • One relatively small study found that in 250
    patients with acute chest and/or back pain,
    certain findings were particularly relevant
    sudden onset of tearing/ripping chest pain,
    widening of mediastinum or aorta (or both), and
    pulse or BP differentials (or both).
  • Absense of all three, low probability (7)
  • Characteristic chest pain, intermediate
    probability (31)
  • Mediastinal Widening, intermediate probability
    (39)
  • Pulse/BP differential, high probability (gt83)
  • Combination of all three, high probability (gt83)

8
Bottom line is that you need imaging to assist in
the diagnosis
9
Imaging Studies
  • CXR abnormal in majority of patients (90
    sensitive), but cannot rule out dissection
    (although completely normal imaging is helpful)
  • CT up to 98 sensitive and up to 100 specific
    (depending on the study)
  • TEE up to 98 sensitive 95 specific
  • MRI sensitivity specificity gt98
  • Aortography sensitivity lt90

10
Acute Management
  • Risk of death for untreated acute dissection is
    estimated at 1 per hour
  • IV antihypertensives (goal of SBP lt120 or lower
    if tolerated) and negative ionotropic agents
    (goal HR lt 60)
  • Pain control
  • Cardiac monitoring, preparation for aggressive
    resuscitation
  • Ultimate goal initially is to prevent death and
    irreversible end-organ damage

11
From www.ajronline.org/cgi/content-nw/full/183/1/
109/FIG1
12
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14
Definitive Therapy
  • Ascending Dissections ? Surgery ASAP
  • Descending Dissections
  • If stable and uncomplicated managed medically
  • If unstable or complications surgery

15
Subsequent Management
  • Blood pressure control the lower, the better
  • Serial imaging with MRI/CT on annual basis to
    evaluate for aneurysm formation, anastomotic
    leakage, recurrent dissection
  • Consideration of second operation to repair
    aforementioned complications
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