Aortic dissection

Aortic dissection typically presents in men older than 50 years of age, with sudden onset of severe ripping or tearing substernal or interscapular pain. Patients typically describe the pain as severe “sharp” or “stabbing”, maximal at onset.

May present with syncope, heart/renal failure, or mesenteric or limb ischemia; oxygen/advanced life support protocol and hemodynamic support should be instituted without delay when the condition is suspected.

Diagnostic modalities include computed tomography scan, magnetic resonance imaging, or transthoracic/transesophageal echocardiography.

Involvement of the ascending aorta and/or arch warrants urgent surgical repair. Dissections of the descending aorta are managed medically with beta blockade; surgery in this group is reserved for those with end-organ malperfusion, persistent pain, rapid aneurysmal degeneration, or rupture.

Lifelong surveillance is needed with regular imaging to detect delayed aneurysmal degeneration of the remaining aorta, 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. Type A dissection involves the ascending aorta, with or without involvement of the arch and descending aorta.[1]Crawford ES, Svensson LG, Coselli JS, et al. Surgical treatment of aneurysm and/or dissection of the ascending aorta, transverse aortic arch, and ascending aorta and transverse aortic arch. Factors influencing survival in 717 patients. J Thorac Cardiovasc Surg. 1989 Nov;98(5 Pt 1):659-73. http://www.ncbi.nlm.nih.gov/pubmed/2811404?tool=bestpractice.com Type B does not involve the ascending aorta, and predominantly involves only the descending thoracic (distal to the left subclavian artery) and/or abdominal aorta.[1]Crawford ES, Svensson LG, Coselli JS, et al. Surgical treatment of aneurysm and/or dissection of the ascending aorta, transverse aortic arch, and ascending aorta and transverse aortic arch. Factors influencing survival in 717 patients. J Thorac Cardiovasc Surg. 1989 Nov;98(5 Pt 1):659-73. http://www.ncbi.nlm.nih.gov/pubmed/2811404?tool=bestpractice.com  The Society for Vascular Surgery and Society of Thoracic Surgeons have proposed that aortic dissection be divided into 4 phases, based on time from onset of symptoms: hyperacute (<24 hours), acute (1-14 days), subacute (15-90 days), and chronic (>90 days).[2]Lombardi JV, Hughes GC, Appoo JJ, et al. Society for Vascular Surgery (SVS) and Society of Thoracic Surgeons (STS) reporting standards for type B aortic dissections. J Vasc Surg. 2020 Mar;71(3):723-47. https://www.doi.org/10.1016/j.jvs.2019.11.013 http://www.ncbi.nlm.nih.gov/pubmed/32001058?tool=bestpractice.com