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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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acute aortic dissection

Acute Aortic Dissection

AM Report 6/29/09

Brandon M. Williams, MD

classification
Classification
  • Two systems:
  • DeBakey
  • Daily (Stanford) = most used
debakey
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
Daily (Stanford)
  • Type A: involves ascending aorta
  • Type B: all others

- Nomenclature doesn’t change secondary to site of origin

pathophysiology
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
Incidence
  • Acute aortic dissection

- 2.6-3.5/100,000 person years

incidence1
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
Risk Factors
  • 13% with known aortic aneurysm (19% if < 40yo)
  • Inflammatory disease vasculitis

-giant cell arteritis

-takayasu arteritis

-rheumatoid arthritis

-syphilitic aortitis

risk factors1
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
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
Diagnosis
  • Abrupt onset of pain, tearing/ripping
  • Mediastinal/aortic widening on Chest X ray
  • Variation in pulse
imaging
Imaging
  • Chest Xray
  • TTE
  • TEE
  • CTA chest
  • MRI
  • Coronary angiography
treatment
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
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
  • Google images