Updated: 12/12/2020

Aortic Dissection

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Snapshot
  • A 32-year-old man with eunuchoid proportions and arachnodactyly presents to the emergency department with severe substernal chest pain that radiates to the back. He says that the pain occurred acutely and denies any recent trauma. Medical history is significant for Marfan syndrome. On physical exam, there are unequal blood pressures in the upper extremity. A chest radiograph demonstrates a widened mediastinum. A CT angiography demonstrates a Stanford A type aortic dissection.
Introduction
  • Clinical definition
    • a separation of the media laminal planes, resulting in a blood-filled space in the aortic wall 
      • there are two types of aortic dissection
        • Stanford A type
          • a dissection involving the ascending aorta 
        • Stanford B type
          • a dissection involving only the descending aorta
  • Etiology
    • hypertension (most common) 
    • connective tissue disease
    • iatrogenic (e.g., coronary catheterization)
    • trauma 
  • Pathogenesis
    • an intimal tear of the aorta causes an intramural aortic hemorrhage that separates the intima from the media
      • the resulting hematoma may rupture through the adventitia, leading to a thoracic or abdominal cavity hemorrhage or cardiac tamponade
  • Associated conditions
    • Marfan syndrome 
    • bicuspid aortic valve
      • e.g., Turner syndrome
  • Prognosis
    • Stanford type A
      • effective blood pressure control and surgical treatment improves mortality
    • Stanford type B
      • effective conservative or surgical treatment improves mortality
Presentation
  • Symptoms
    • acute chest or back pain (most common) 
      • classically anterior chest pain that radiates to the back between the scapulae
  • Physical exam
    • unequal blood pressures in the arms
    • weak or absent pulses
    • diastolic decrescendo murmur when the aortic valve is involved
      • resulting in aortic regurgitation
Imaging
  • Radiography of the chest
    • indication
      • to rule out other causes of chest pain (e.g., pneumothorax)
    • finding
      • widened mediastinum
  • CT angiography of the chest
    • indication
      • most accurate imaging test for aortic dissection 
      • MR angiography of the chest can be used in stable patients with iodine contrast allergies 
  • Transesophageal echocardiography 
    • can be used if kidney injury is present or patient is allergic to contrast 
Differential
  • Myocardial infarction 
    • differentiating factors
      • an electrocardiogram may be present (e.g., ST-segment elevation)
      • increased cardiac biomarkers
Treatment
  • Medical
    • β-blockers 
      • indication
        • Stanford type B aortic dissection
  • Surgical
    • vascular surgery
      • indication
        • Stanford type A aortic dissection
Complications
  • End-organ damage
    • secondary to poor perfusion
      • acute renal failure
      • acute abdomen
      • mesenteric ischemia 
      • ischemic colitis
      • paraplegia or weakness of lower extremities
      • aortoiliac occlusive disease
      • aortic regurgitation 
  • Aneurysm rupture
  • Myocardial infarction from coronary artery occlusion
  • Stroke from dissection extending into carotids
  • Aortic regurgitation
  • Cardiac tamponade

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(M2.CV.17.4692) A 62-year-old male with hypertension, diabetes, and coronary artery disease presents with sudden onset chest pain for the past two hours. The patient describes the pain as a tearing sensation in the center of his chest without any radiation. The patient endorses feeling nauseous and sweaty. The patient’s vitals signs are as follows: temperature is 98.7 deg F (37.1 deg C), blood pressure is 173/68 mmHg, pulse is 92/min, respirations are 14/min. An electrocardiogram demonstrates left axis deviation but no ST segment changes, Q waves, left bundle branch morphology, or T wave inversions are seen. The patient’s troponin level is 0.05 ng/mL. A chest radiograph demonstrates the following findings (Figure A). Which of the following is the most appropriate next diagnostic step?

QID: 107672
FIGURES:
1

Esophagogastroduodenscopy

20%

(1/5)

2

Transthoracic echocardiogram

40%

(2/5)

3

Left heart catheterization and angiogram

0%

(0/5)

4

Thoracic and abdomen CT angiogram

40%

(2/5)

5

Thoracic and lumbar spine radiograph

0%

(0/5)

M 6 B

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Evidence (13)
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