AORTIC DISSECTION

Definition

Aortic dissection occurs when blood dissects between the intimal and adventitial layers of the aorta,

Symptoms

1. acute chest pain most severe at onset and radiates to the back (sharp, ripping, or tearing)

2. aortic valve insufficiency,

3. coronary artery occlusion with myocardial infarction,

4. carotid involvement with stroke symptoms,

5. occlusion of vertebral blood supply with paraplegia,

6. cardiac tamponade with shock and jugular venous distention,

7. compression of the recurrent laryngeal nerve with hoarseness of the voice,

8. and compression of the superior cervical sympathetic ganglion with Horner’s syndrome.

9. diastolic murmur of aortic insufficiency

10. Hypertension and tachycardia ( but hypotension also may be present.)

Risk factor

1. Male , older then 50 year

2. Hx of hypertension

3. Chronic cocaine use

4. Connective tissue disease

5. Congenital heart disease

6. Pregnancy

7. Marfan syndrome

classification

Stanford classification

• ascending aorta (type A)

• descending aorta (type B)

DeBakey classification

• ascending and descending aortas (type I),

• involvement of only the ascending aorta (type II),

• involvement of only the descending aorta (type III)

differential diagnosis

1. myocardial infarction,

2. peri- cardial disease,

3. stroke,

4. spinal cord disorders,

Investigation

1. D dimer

2. Chest x ray :

   • abnormal aortic contour

   • widening of the mediastinum,

   • deviation of the trachea, mainstem bronchi, or esophagus,

   • apical capping,

   • pleural effusion,

   • displacement of aortic intimal calcifications.

3. CT scan with IV contrast

4. Transesophageal echo

CT image of a type A aortic dissection. True and false lumens are

present in the ascending aorta and descending aorta (descending false lumen at

arrow) on noncontrast (left) and contrast (right) images. AF, ascending false lumen;

AT, ascending true lumen; DT, descending true lumen.

Treat

1. Stabilize hemodynamics with large-bore IV access, IV fluids for hypotension, and blood transfusion when required

2. Manage hypertension with β-blockers such as esmolol 0.1 to 0.5 mg/kg IV bolus followed by a 0.025 to 0.2 mg/kg/min infusion, or labetolol 20mg IV followed by subsequent doses of 20 - 40 mg IV every 10 min.

3. Reduce the heart rate to a goal of between 60 and 70 beats per minute and the systolic blood pressure to a goal of 100 to 120 mm Hg.

4. Additional blood pressure reduction with agents such as nitroprusside or nicardipine should be used when needed after adequate inotropic blockade has been achieved and systolic blood pressures remain above 120 mm Hg