Aortic dissection typically presents with abrupt onset chest, back, or abdominal pain that is severe in intensity or is described as ripping or tearing, particularly in the patient with a high risk condition (such as Marfan syndrome) or a family history of aortic disease. Although a typical patient with aortic dissection is a male in his 50s, always consider the diagnosis in younger patients even if they have no risk factors.
Other features include syncope, heart/renal failure, and mesenteric or limb ischaemia; institute oxygen/advanced life support protocol and haemodynamic support without delay if you suspect dissection.
ECG, chest x-ray, transthoracic echocardiography, and blood tests (to detect complications of aortic dissection or other differentials) are required for initial diagnostic work-up for all patients. Computed tomography scan is first-line for definitive diagnosis. Further investigations may include trans-oesophageal echocardiography, magnetic resonance imaging, and D-dimer.
Involvement of the ascending aorta and/or arch (Stanford type A) warrants urgent surgical repair. Dissections of the descending aorta (Stanford type B) are managed medically to control the patient’s heart rate and blood pressure; surgery in this group is reserved for those with complications such as rupture, visceral or extremity ischaemia, or persistent or recurrent pain.
Lifelong surveillance is needed with regular imaging to detect complications which may later require surgery.
Aortic dissection describes the condition when a separation has occurred in aortic wall intima, causing blood flow into a new false channel composed of the inner and outer layers of the media. Dissection most commonly occurs with a discrete intimal tear, but can occur without one. An aortic dissection is considered acute if the process is less than 14 days old.
History and exam
Key diagnostic factors
- acute severe chest pain
- interscapular and lower pain
- left/right blood pressure differential
- pulse deficit
- diastolic murmur
- features of Marfan syndrome
- features of Ehlers-Danlos syndrome
Other diagnostic factors
- altered mental status
- abdominal pain
- limb pain/pallor
- left-sided decreased breath sounds/dullness
- atherosclerotic aneurysmal disease
- Marfan syndrome
- Ehlers-Danlos syndrome
- bicuspid aortic valve
- annulo-aortic ectasia
- family history of aortic aneurysm or dissection
- older age
- giant cell arteritis
- overlap connective-tissue disorders
- surgical/catheter manipulation
- cocaine/amphetamine use
- heavy lifting
1st investigations to order
- chest x-ray
- CT (chest, abdomen, and pelvis)
- high-sensitivity troponin
- renal function tests
- liver function tests
- full blood count
- C-reactive protein
- group and save/cross match
- blood gas
- creatine kinase
Investigations to consider
- magnetic resonance angiography
- intravascular ultrasound
suspected aortic dissection: haemodynamically unstable
confirmed type A aortic dissection
confirmed type B aortic dissection: complicated
confirmed type B aortic dissection: uncomplicated
chronic aortic dissection
Ian Chetter, MBChb, FRCS (eng), MD, FRCS (Gen surg), PGCert Medical Ultrasound, PGDip Clinical Education
Chair of Surgery
University of Hull
Honorary Consultant Vascular Surgeon
Hull University Teaching Hospitals NHS Trust
IC is Editor in cheif for the Journal of Vascular Societies Great Britain and Ireland, and the research chair for the Vascular Society of Great Britain and Ireland. IC is also a member of NIHR Prioritising Committee, and has recieved research grants from the NIHR.
Alexander Alexiou, MBBS, BSc, DCH, FRCEM, Dip IMC, RCSEd
Emergency Medicine Consultant
Barts Health NHS Trust
Physician Response Unit Consultant
London’s Air Ambulance
Royal London Hospital
AA declares that he has no competing interests.
BMJ Best Practice would like to gratefully acknowledge the previous expert contributors, whose work has been retained in parts of the content:
Caitlin W. Hicks MD, MS
Assistant Professor of Surgery
Division of Vascular Surgery and Endovascular Therapy
The Johns Hopkins University School of Medicine
James H. Black III MD, FACS
Chief Vascular Surgery and Endovascular Therapy
Department of Surgery
The Johns Hopkins University School of Medicine
CWH declares that she has no competing interests. JHB is a proctor for Cook, Inc.
Greg McMahon, MD, FRCS
Consultant Vascular Surgeon
University Hospitals of Leicester NHS Trust
Honorary Lecturer, College of Life Sciences
University of Leicester
GM declares that he has no competing interests.
Section Editor and Comorbidities Editor, BMJ Best Practice
AS declares that she has no competing interests.
Lead Section Editor, BMJ Best Practice
RW declares that she has no competing interests.
Drug Editor, BMJ Best Practice
AM declares that he has no competing interests.
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