Aortic Dissection

Question 1

What is aortic dissection

Answer 1

Tear in the aortic wall intima- causing blood to flow into a new false lumen in the intima-media space
Can cause a haematoma to form and rupture causing occlusion of vessels

Question 2

Epidemiology

Answer 2

60-80 year old

Question 3

How old are patients with Marfan syndrome and why is this relevant

Answer 3

30-50
Connective tissue disorders predispose to both aneurysms and dissections

Question 4

What part of the aorta is usually affected

Answer 4

Most commonly the ascending aorta

Question 5

Describe the Stanford classification

Answer 5

Stanford type A (more common)- any dissection involving the ascending aorta

Standford type B- any dissection involving the descending aorta only (distal to left subclavian artery)

Question 6

Describe the DeBakey classification

Answer 6

Type 1- involves ascending and descending aorta
Type 2- only ascending aorta up to brachiocephalic artery
Type 3- only descending aorta distal to left subclavian artery

Question 7

What is the most important risk factor

Answer 7

Hypertension

Question 8

What are other risk factors

Answer 8

Trauma
Marfan’s syndrome
Smoking

Question 9

What are the features of Marfan syndrome

Answer 9

Disorder of the body’s connective tissue

Tall and high arched palate
Pectus excavatum- where the sternum is sunken inwards
Joint hyper mobility
Autosomal dominant condition

Question 10

What are the clinical features of aortic dissection

Answer 10

Sudden and severe tearing chest pain
Inter capsular pain radiating to the back
Asymmetrical BP and pulse between limbs (mostly arms)- weak or absent carotid, brachial or femoral pulse, radio-radial delay, radio-femoral delay
Early diastolic murmur (aortic regurgitation) in ascending aorta dissection
Focal neurological deficits

Question 11

What is an Austin flint murmur

Answer 11

Mid-diastolic murmur best heard at the apex
Sign of severe aortic regurgitation

Question 12

What is the 1st line imaging for definitive diagnosis

Answer 12

CT angiogram of chest, abdomen and pelvis (CT CAP)- can see false lumen

CT aortogram

Question 13

What investigation can be done for patients who are unstable and can’t be taken to a CT?

Answer 13

Transoesophageal echocardiogram

Question 14

What would CXR show

Answer 14

Widened mediastinum

Question 15

What must you always perform in patients with acute chest pain and why

Answer 15

ECG to rule out STEMI

Question 16

What could bloods show

Answer 16

Raised d dimer with normal troponin
High troponin
Low Hb
High lactate and metabolic acidosis on Venous blood gas

Question 17

What does d-dimer measure

Answer 17

Level of fibrin degradation
High d-dimer- significant clot formation and breakdown somewhere in the body

Question 18

What is the management for type A

Answer 18

Beta blocker + surgical management- ASS (aortic root replacement & surgery)

Question 19

What is meant by complicated aortic dissection

Answer 19

Evidence of end organ ischaemia

Question 20

What is meant by complicated aortic dissection

Answer 20

Evidence of end- organ ischaemia

Question 21

What is the management of type B

Answer 21

Bed rest
IV beta blockers (Labetalol) to reduce BP
Analgesia
For hypotensive patients- IV fluids and vasopressin

Question 22

Prognosis complication

Answer 22

Left untreated, can be fatal in 50-60% of patients within 24 hours