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Acute Aortic Dissection - PowerPoint PPT Presentation
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Acute Aortic Dissection. AM Report 6/29/09 Brandon M. Williams, MD. Classification. Two systems: DeBakey Daily (Stanford) = most used. DeBakey. Type 1: origin in ascending aorta and propagates to at least arch Type 2: origin in ascending and confined within ascending
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Presentation Transcript
Classification
- Two systems:
- DeBakey
- Daily (Stanford) = most used
DeBakey
- Type 1: origin in ascending aorta and propagates to at least arch
- Type 2: origin in ascending and confined within ascending
- Type 3: origin in descending and extends (distally or proximally)
Daily (Stanford)
- Type A: involves ascending aorta
- Type B: all others
- Nomenclature doesn’t change secondary to site of origin
Pathophysiology
- Tear in aortic intima
- Need degeneration of media or cystic medial necrosis for nontraumatic dissections
- Blood crosses into media via tear and separates intima from media/adventitia creating a false lumen
- ? If rupture of intima or hemorrhage within media causing rupture of intima is initiating event
Incidence
- Classic is 60 – 80 yo males (mean 63yo)
- Women 67
- Ascending 2x more likely than descending, with right lateral wall most common site
Risk Factors
- 13% with known aortic aneurysm (19% if < 40yo)
- Inflammatory disease vasculitis
-giant cell arteritis
-takayasu arteritis
-rheumatoid arthritis
-syphilitic aortitis
Risk Factors
- HTN (71%)
- Atherosclerosis (31%)
- DM (5.1%)
- Collagen disorders (Marfan, Ehlers-Danlos)
- 19% of thoracic with family history
- Bicuspid aortic valve (9% < 40yo)
- Aortic coarctation (post intervention)
- CABG
- AVR
- Cardiac catheterization
- Trauma
- High-intensity weight lifting and cocaine via transient HTN
- cocaine 37% of AA inner city population
Signs and Symptoms
- Abrupt, tearing pain, back (if distal to L subclavian) or anterior (ascending)
- Associated: syncope, CVA, MI, HF
- Syncope assoc with worse outcome (almost all type A)
- Pulse deficit
- Aortic insufficiency: murmur more at RSB than valve assoc AI (LSB)
- >20mmHg difference in SBP between UE
- Vocal cord paralysis (compression of L laryngeal nerve)
- Hypotension (hemorrhage, tamponade, HF)
- Spinal cord ischemia
- “STEMI:” 3/820 EKGs showing STEMI found to have ascending aortic dissection
Diagnosis
- Abrupt onset of pain, tearing/ripping
- Mediastinal/aortic widening on Chest X ray
- Variation in pulse
Imaging
- Chest Xray
- TTE
- TEE
- CTA chest
- MRI
- Coronary angiography
Treatment
- Involvement of ascending aorta = surgical emergency
- Descending aorta: medical management unless progression or hemorrhage into pleural or retroperitoneal space
-morphine
-SBP 100-120 or lowest tolerated
*beta blocker titrate to HR < 60 (labetalol, propranolol, esmolol)
*if beta blocker intolerant: verapamil, diltiazem
*no nitroprusside until HR < 60
*no hydralazine
*no inotropic agents, if hypotensive look for bleeding
- A-line in radial artery with highest auscultatory pressure
References
- UpToDate
- Management of Patients with Aortic Dissection. Weigang et al. Dtsch Arztebl Int. 2008 Sep. 105 (38) 639-645
- Conditions mimicking acute ST-segment elevation myocardial infarction in patients referred for primary percutaneous coronary intervention. Gu et at. Neth Heart Journal. 2008 Oct: 16 (10) 325-31
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