A small tear forms in this layer, and, if left untreated, it can enlarge. Setting the international registry of acute aortic dissection, consisting of 12 international referral centers. Its clinical presentation is variable and can mimic any number of medical and surgical conditions. Acute aortic dissection is the most common lifethreatening disorder affecting the aorta. Surgery for aortic dissection surgeons either insert a tube called a stent to prevent blood from flowing into the false lumen that forms between the layers of the aorta during a dissection, or they replace the damaged parts of the aorta with a synthetic material. Sep 19, 2008 acute aortic dissection is often accompanied by sudden stabbing back pain 53%, which sometimes follows the course of the aorta in craniocaudal direction 17%. As a trainee, i read the chapters discussing all the classifications and discussions of the biomechanics and felt quite intimidated by the all the moving parts involved in an aortic dissection, and i missed the main point about tbad. The surgery involved in repairing an aortic dissection is very difficult and invasive. Chest xray will sometimes show a widened mediastinum.
Surgical repair in the acute dstal aortic dissection phase is associated with high morbidity and mortality. Aortic dissection is a serious condition in which there is a tear in the wall of the major artery carrying blood out of the heart aorta. Dissection can be classified by the sites involved. Irad is a multicenter registry of all cases of acute aortic dissection at participating sites. Pdf acute type a aortic dissection involving the iliac. We sought to determine associations for development of proximal progression or new type a aortic dissection ntad after acute type b dissection atbd and its effect on survival of the patient. As has been stated before, type a dissections require immediate surgical repair. Red flags for the emergency triage nurse published by the nationalmarfanfoundation 22manhassetavenue portwashington,ny11050. Morales e, on behalf of the define investigators objectivebackground. Stanford classification of aortic dissection radiology.
Aortic dissection is the retinal detachment of the torso on pocus. Aortic dissection is the most common catastrophic condition affecting the aorta. Dake md, in comprehensive vascular and endovascular surgery second edition, 2009. Usually the causative factor is an underlying disease of the media.
The rate of aortic dissection was higher during the pregnancy and postpartum period 5. The incidence of acute aortic dissection has been estimated to be approximately 3 per 100,000 persons, but more recently the rate has increased to 6 per 100,000. Mainoutcomemeasures presenting history, physical findings, management, and. It receives oxygenrich blood from the heart and distributes it to the body through smaller. A false lumen yellow arrow is seen in the above aortic dissection in the united states, aortic dissection occurs most frequently in hypertensive patients. Two populationbased studies indicated incidences of 2. Aortic dissection red flags for the emergency triage nurse e m e r g e n c y m e d ic n e c a m p a i g n publishedbythe nationalmarfanfoundation. Prompt diagnosis and management of aortic dissection are key to reduce patient morbidity and mortality. However, it was not until the midtwentieth century that the first large case series was published and the first surgical resection was performed. The estimated incidence is 530 cases per million people per year.
Uncomplicated acute type b aortic dissections are usually treated medically, but they can become acutely complicated by rapid expansion, rupture and malperfusion syndromes and in the longer term by chronic dilatation and aortic aneurysm formation. Aortic dissection is a catastrophic cardiovascular condition first described in detail by frank nicholls in his necropsy report of king george ii. Aortic dissection surgery saves lives and funds research. We present a rare case of continuous, extensive aortic dissection ad involving the bilateral common carotid arteries, the ascending, thoracic, and abdominal aorta, and bifurcation of the right common iliac artery.
Perhaps nowhere is this shift in approach more apparent than in the treatment of acute aortic. Aortic dissection zahir rahman md 101402 slideshare uses cookies to improve functionality and performance, and to provide you with relevant advertising. The flap is seen involving the ascending aorta, without involvement of the coronaries, the arch and descending aorta and extends distally to the aortic bifurcation. The dissection may occur anywhere along the aorta and extend proximally or distally into other arteries. Although his death marked the end of an era, the circumstances surrounding the surgery for his acute dissection revealed all of the challenges that we as cardiovascular surgeons face when treating the elderly. During the first two weeks acute phase, lifethreatening complications due to branch involvement or aortic rupture are more likely to occur compared with the timeframe past two weeks chronic phase. Blood can pass through the tear into the middle layer of the wall, causing the layers to separate from one another, or dissect. The objective of this study is to use computational fluid dynamics reconstructions of type b aortic dissections to. New paradigms in the treatment of acute complicated and. Surgeons either insert a tube called a stent to prevent blood from flowing into the false lumen that forms between the layers of the aorta during a dissection, or they replace the damaged parts of the aorta with a synthetic material.
A new study shows improved patient outcomes with extensive repair of aortic dissection. This study, using the international registry of aortic dissection irad, helps elucidate patient and disease characteristics associated with recurrent aortic dissection. The most prevalent symptom is excruciating chest pain. The longterm, multicenter project may generate predictive tests and targeted preventative and therapeutic strategies. The objective of this study is to use computational fluid dynamics reconstructions of type b aortic dissections to compare geometric and. Dec 18, 2019 a false lumen yellow arrow is seen in the above aortic dissection in the united states, aortic dissection occurs most frequently in hypertensive patients. Both false and true lumina are patent with no evidence of occlusion of any of the aortic branches. A 61yearold man with history of chronic hypertension presented with a oneday history of chest pain, vertigo, left facial drooping, and left hemiparesis. Acute type b aortic dissection comprises approximately onethird of all aortic dissection cases. Acute aortic syndromes are a constellation of lifethreatening medical conditions, including classic acute aortic dissection aad, intramural haematoma imh, penetrating atherosclerotic aortic ulcer pau even thoracic aortic rupture, which share common pathophysiological pathways breakdown of the intima and media, clinical. Findings are published in the annals of thoracic surgery.
Jan 08, 2019 aortic dissection see the image below is defined as separation of the layers within the aortic wall. An aortic dissection is an often fatal disorder in which the inner layer lining of the aortic wall tears and separates from the middle layer of the aortic wall. Look for marphans, listen for an aortic regurgitation murmur. Lindsay is initiating a largescale collection of genetic samples from people who have experienced aortic dissection. Tears in the intimal layer result in the propagation of dissection proximally or distally secondary to blood entering the intimamedia space. If aortic dissection is suspected, the patient must immediately be taken to a cardiovascular surgery center with an emergency physician in attendance. In 2014, a special report was published in radiology 4 that recognized an uncommon form of aortic dissection. Ddimer rule out aortic dissection em cases journal. Management of acute aortic dissection christoph a nienaber, rachel e clough a new appraisal of the management of acute aortic dissection is timely because of recent developments in diagnostic strategies including biomarkers and imaging, endograft design, and surgical treatment, which have led to a better. Aortic dissection and its variants stanford university. Remember the big pain pearls when taking a history.
Geometric and flow features of type b aortic dissection. A patient has an intravenous iv line placed, so that medications can be delivered directly into the blood stream. Retrograde ascending aortic dissection occurred during the tevar procedure n 7, 15%, before the procedure during the index hospitalization n 10, 21%, and after discharge during followup n 31, 65% table 3 and figure 1. New paradigms in the treatment of acute complicated and uncomplicated type b aortic dissection. In 22 of 48 46% patients, raad occurred within the first 30 days. Aortic dissection cardiovascular disorders merck manuals. This system takes into account the location of the original intimal tear and the extent of the dissection. In addition it strongly emphasizes basic principles in medicine. Aortic dissections in the elderly pubmed central pmc. The diagnosis of aortic dissection is based on clinical suspicion combined with imaging studies. Continuing on with the theme of acute aortic dissections, lets discuss in more detail the ramifications and consequences of blood simultaneously flowing in two separate, parallel channels within the aorta.
This occurs because the enlarged aorta casts a larger shadow on the xray detector. It is part of the acute aortic syndrome an umbrella term for aortic dissection, intramural haematoma, and symptomatic aortic ulcer table. As the tear extends along the wall of the aorta, blood can flow in between the layers of the blood vessel wall dissection. The em cases team is very excited to bring you not only a new format for the journal jam podcast but a new member of the team, dr.
Aortic dissection involves a tear in the medial layer of the aortic wall, causing blood to extravasate into the media and thus compromising blood flow to the brain, heart, and other organs. The double barrel appearance in cross section of the aorta means that the physiologic pressure of the of a single channel of flowing blood in the normal. An aortic dissection, or tear in the aorta, typically occurs when the inner layer of the arterys wall weakens. Aortic dissection is a more common problem than is ruptured abdominal aortic aneurysm. Combined thoracic aortic dissection and abdominal aortic. Ddimer rule out aortic dissection em cases journal jam.
The intimal tear may be a primary event or secondary to hemorrhage within the media. Mortality is still high despite advances in diagnostic and therapeutic modalities. Not defined in stanford classification aortic arch. Type b aortic dissections tbad are frequently seen here at the clinic as we serve as a regional referral center. Retrograde ascending aortic dissection during or after. Other studies were omitted due to methodological limitations. A read is counted each time someone views a publication summary such as the title, abstract, and list of authors, clicks on a figure, or views or downloads the fulltext. Participants a total of 464 patients mean age, 63 years. Aortic dissection information guide a o r t i c d i s s e c t i o n m a r d i g i a n w e l l n e s s r e s o u r c e c e n t e r page 1. Blood surges through the tear, causing the inner and middle layers of the aorta to separate dissect. New type a dissection after acute type b aortic dissection. In the operating room, a cardiothoracic surgeon first performs a median sternotomy, a procedure in which a patients chest is opened.
Aortic dissection is a medical emergency and can quickly lead to death should the bloodfilled section rupture through the outside aortic wall. Abrupt and severe retrosternal or inter scapular chest pain is sometimes felt as a tear, with subsequent migration down the back occurs in 90% of patients. The initial management for an aortic dissection often occurs in the emergency room. I used meshmixer to add the supports and combine the two segments. Aortic dissection, though uncommon, when it occurs, it is most frequently in men aged 60 to 70. Essential treatment includes rapid initiation of pharmacologic agents to control hypertension. Combined use of aortic dissection detection risk score and ddimer in the diagnostic workup of suspected acute aortic dissection. Modeling of predissection aortic size in acute type a. The timing and need for intervention surgicalendovascular differs for ascending type a and descending type b.
Aortic dissection is caused by an intimal and medial tear in the aorta with propagation of a false lumen within the aortic media. Aortic dissection heart and blood vessel disorders merck. A new mnemonicbased approach to the categorization of aortic dissection m. An aortic dissection is a serious condition in which the inner layer of the aorta, the large blood vessel branching off the heart, tears. Aortic dissection is classified, somewhat arbitrarily, as acute or chronic based upon the duration of symptoms at the time of presentation. Aortic dissection is a relatively rare but highly lethal disease. Type a aortic dissection after nonaortic cardiac surgery. Eagle, md,x valentin fuster, md, phd abstract aortic dissection is the most devastating complication of thoracic aortic disease. If this is seen, and there is a high clinical suspicion of a dissection, a ct scan of the chest with. When an aortic dissection is detected early and treated promptly, chance of survival greatly improves. Aortic dissection uf health, university of florida health. For untreated acute dissection of the ascending aorta, the mortality rate is 12% per hour early after symptom onset. Aortic dissection heart and blood vessel disorders.
The most important inherited connective tissue diseases involving the aortic wall are marfan syndrome mfs and ehlersdanlos syndrome eds, along with the familial types of thoracic aortic aneurysm and aortic dissection. Feb 22, 2010 aortic dissection zahir rahman md 101402 slideshare uses cookies to improve functionality and performance, and to provide you with relevant advertising. Aortic dissection is the surging of blood through a tear in the aortic intima with separation of the intima and media and creation of a false lumen channel. For a deep dive into the worlds literature on ddimer for aortic dissection visit em cases journal jam 9. While the sensitivity of pocus by ed physicians to detect an intimal flap is only 67%, the specificity has been shown to be 99100%. Journal jam 9 ddimer to rule out aortic dissection view larger image the em cases team is very excited to bring you not only a new format for the journal jam podcast but a new member of the team, dr. Aortic dissection an overview sciencedirect topics. What is the classic clinical presentation of a dissecting aorta. The international registry of acute aortic dissection irad. If the bloodfilled channel ruptures through the outside aortic wall, aortic dissection is often fatal. The debakey classification system is an anatomical description of the aortic dissection figure 6. This can lead to aortic rupture or decreased blood flow ischemia to organs.
Blood pressure is reduced with medications, usually to 100 to 120 mmhg systolic. Aortic dissection stanford classification type a type b ascend. Patients with type b aortic dissection often present as a spectrum of acute aortic syndromes, including intramural hematoma, penetrating aortic ulcers, aortic dissection and aneurysms. Pdf acute aortic dissection is the most frequent and deadly presentation of acute aortic syndromes. An extensive stanford type a aortic dissection involving. The incidence of type a dissection was greater among men, with the average ratio of 3. Apr 14, 2017 one file has supports built into the design, if you are printing on a fdm printer. Although this catastrophic cardiovascular condition was first described in the medical literature over two centuries ago, data on the optimal diagnostic and treatment modalities for type b dissection was slow to evolve throughout the latter half of the twentieth century, even as newer diagnostic. Arterial hypertension is an important predisposing factor for aortic dissection. The authors describe dissections that originate from the arch or extend proximally into the arch without the involvement of the. Drawing of the aorta in a 63yearold man who had an acute myocardial infarct at age 60 years that healed. Aortic dissection is a tear in the wall of the aorta which causes the inner and middle layers of the aorta to separate.
If you continue browsing the site, you agree to the use of cookies on this website. The goals of early management of aortic dissection are to control pain and limit the extension of the dissection using antiimpulse therapy, which typically involves administration of beta blockers and control of blood pressure. Symptoms and clinical findings often depend on the extent and involvement of dissection. Mfs is the most frequent congenital connective tissue disorder, occurring in 1 in 7000 births with autosomal dominant inheritance. We believe its important to report this case because it underscores the relationship between cocaine abuse and aortic dissection. Aortic dissection is a dynamic process that can progress both proximal and distal to the initial entry tear. The extent of a dissection is classified using one of two systems. Take home points for aortic dissection diagnosis and management.