Aortic Dissections

Question 2

What is an aortic dissection?

Answer 2

A tear in the intimal layer of the aortic wall causing blood to flow between the tunica intima and media, splitting the two apart

Acute < or equal to 14 days to diagnosis

Chronic > 14 days to diagnosis

Question 3

How can aortic dissections be classified?

Answer 3

Stanford Classification

A - Debakey Type I and II involving ascending aorta

B - Debakey Type III and do not involve ascending aorta

DeBakey Classification

I - originates in ascending aorta and propagates to at least aortic arch

II - confined to asending aorta

III - originates distal to subclavian artery in descending aorta

Question 4

What are some risk factors for an aortic dissection?

Answer 4

• Hypertension
• Atherosclerotic diease
• Male
• Connective tissue disorders (Marfan’s and EDS in younger pt)
• Bicuspid aortic valve

Question 5

What are the clinical features of an aortic dissection and what are some differentials?

Answer 5

- Tearing chest pain that usually radiates to back

- Tachycardia, hypotension, aortic regurg murmur

• Signs of end-organ hypoperfusion e.g reduced urine output, lower limb ischaemia

DD: MI, PE, Pericarditis, MSK back pain

Question 6

How do you investigate a suspected aortic dissection?

Answer 6

• Bloods (FBC, U+Es, LFTs, troponin, coagulation) with crossmatch of at least 4 units
• ABG
• ECG to rule out cardiac pathology

- CT angiogram diagnosis gold standard 1st line

• Can do transoesophageal ECHO

Question 7

How should you manage an aortic dissection generally?

Answer 7

- Initial: high flow oxygen, IV access with 2 large bore cannulas, fluid resus with target BP<110

- Stanford A: managed surgically as worse prognosis

- Standford B: can be managed medically if uncomplication

- Lifelong antihypertensive therapy and surveillance imaging at 1,3,12 months

Question 8

How are Type A dissections managed?

Answer 8

• Transfer to cardiothoracic centre
• Remove ascending aorta and replace with synthetic graft
• Reimplant branches of aortic arch to graft

Question 9

How are Type B dissections managed?

Answer 9

MEDICALLY DUE TO RISK OF RETROGRADE DISSECTION IF MANAGENED SURGICALLY

1st line: IV beta blockers (labetolol) or CCB to lower systolic pressure and minimise dissection

Complicated: if rupture, ischaemia, pain or uncontrollable HTN then surgical repair

Question 10

What are some complications of aortic dissections?

Answer 10

• Aortic rupture
• Aortic regurgitation
• MI if coronary artery dissection
• Cardiac tamponade
• Stroke or paraplegia if cerebral or spinal artery involved
• Type B can become chronic and form aneurysm