The initial management for an aortic dissection often occurs in the emergency room. Kaplanmeier survival curve for type b dissection stratified by treatment type. A 55yearold woman developed dic associated with stanford type b aortic dissection, which improved by administration of lowmolecularweight heparin combined with tranexamic acid, but the dissecting. Two populationbased studies indicated incidences of 2.
Dec 04, 2018 disseminated intravascular coagulation dic is an infrequent aortic dissection complication, and its optimal treatment remains controversial. Successful treatment of disseminated intravascular. Etiology, classification, and symptoms aortic dissection acute aortic dissection is defined as dissection occurring within 2 weeks of onset of pain 2. An aortic dissection is a tear in the inner lining of the aorta. An aortic dissection is a rare, serious condition in which the inner layer of the aorta the biggest blood vessel in the body, coming directly from the heart tears. An aortic dissection is an emergency with your aorta, which is the largest blood vessel in your body and the main artery that takes blood from your heart to the rest of your body during an. Aortic dissection, intramural hematoma, penetrating atherosclerotic aortic ulcer part i. Eric salter was a 42yearold runner in the prime of his life when in may 2017, on his daughters 11th birthday, he suffered a lifethreatening aortic dissection while sitting at the desk in his home office during an aortic dissection, the inner layer of the aorta the major blood vessel that takes oxygenated blood to the body tears, causing the inner and middle layers to.
Guidelines for diagnosis and treatment of aortic aneurysm and aortic dissection digest version. Aortic dissection occurs when the inner lining of the aorta splits and tears. Treatment of aortic dissection depends upon the location of the tear. Tears in the intimal layer result in the propagation of dissection proximally or distally secondary to blood entering the intimamedia space. Aug 09, 2018 aortic dissection is a medical emergency and needs urgent treatment. Acute aortic dissection and intramural hematoma american. In addition to coronary and peripheral artery diseases, aortic diseases contribute to the wide spectrum of arterial diseases. The intimal tear may be a primary event or secondary to hemorrhage within the media. Aortic dissection is a medical emergency with a high rate of mortality, and early treatment.
Therapy may include surgery or medications, depending on the area of the aorta involved. There are two types of aortic dissection repair surgeries done, open and endovascular. The risk of dying can be as high as one to three percent per hour until the patient gets treatment. It is the treatment of choice for acute complicated dissection, and there is a growing body of evidence in support of tevar during the subacute phase for uncomplicated dissection. We studied 673 patients with type a acute aortic dissection who underwent initial treatment from 1994 through july 2014.
Endovascular treatment of aortic dissection was developed in the 1990s. Management of acute aortic dissection sciencedirect. The rate of aortic dissection was higher during the pregnancy and postpartum period 5. With regard to treatment, labetalol isnt a bad single agent to. The treatment for aortic dissection includes an operation to repair the wall of the aorta, as well as medicines to reduce blood pressure. A tear causes blood to get in between the aortas 3 layers. Dake md, in comprehensive vascular and endovascular surgery second edition, 2009.
Most aneurysms are in the aorta, the main artery that runs from the heart through the chest and. Guidelines for diagnosis and treatment of aortic aneurysm. A patient has an intravenous iv line placed, so that medications can be delivered directly into the blood stream. Having an aneurysm increases the risk of an aortic dissection a tear in the lining of the aorta, shown in the image on the right. Aortic dissection cardiovascular disorders merck manuals. Aortic dissection treatment medstar heart and vascular. This reduces the amount of oxygen and nutrients available for your bodys organs. Two classifications are most commonly used for aortic dissection fig. Once blood enters the lining, it separates the layers of the aortic wall. Patients complain of a sudden onset and severe pain radiating into the thorax, back, or abdomen. Aortic dissection treatment algorithm bmj best practice. These medications reduce blood pressure by blocking the effects of the hormone epinephrine, or adrenaline. The aorta sends blood from your heart to the rest of your body.
Jun 30, 2017 as a result of substantial advances in diagnostic modalities, treatment strategies, and their relative impact on early and late outcomes, the european society of cardiology esc guidelines have recently suggested to further divide the time course of aortic dissection into acute 90 days phases. Medication for aortic dissection nyu langone health. An aortic dissection is a tear dissection in the wall of the bodys main artery, the aorta. Because uncertainties still surround this potentially lethal disease and because its management is shared by many specialties, no fewer than 200 contributions on the subject are published yearly in the medical literature. Blood pressure is reduced with medications, usually to 100 to 120 mmhg systolic. Medication may also be used to stabilize a patients condition before surgery. Patients with uncomplicated type b aortic dissection are usually managed medically with blood pressure and pain control during the acute phase less than 14 days.
Aortic dissection can result either from a tear in the intima and propagation of blood into the media or from intramural haemorrhage and haematoma formation in the media followed by perforation of intima. Our vascular and cardiac surgeons work together to repair even the most complex tears in the bodys largest blood vessel, including using a minimally invasive approach called endovascular repair. Aortic dissection describes the condition when a separation has occurred in aortic wall intima, causing blood flow into a new false channel composed of the inner and outer layers of the media. Pdf the diagnosis and management of aortic dissection. Acute type a aortic dissection complicated by covid19. Treatment for type a aortic dissection may include. Aortic dissection causes, symptoms and treatment patient. Aortic dissection is a medical emergency and needs urgent treatment.
Hypertension is the most prevalent risk factor for acute aortic dissection and is present in up to 75% of cases. The most common risk factor for aortic dissection is poorly controlled hypertension 6575% risk with a history of hypertension 1, 5. Aortic dissection is often fatal but early diagnosis and treatment of aortic dissection can greatly improve survival. Medical management with antihypertensive therapy, including beta blockers, is the treatment of choice for all stable chronic aortic dissections. A new appraisal of the management of acute aortic dissection is timely because of recent developments in diagnostic strategies including biomarkers and imaging, endograft design, and surgical treatment, which have led to a better understanding of the epidemiology, risk factors, and molecular nature of aortic dissection. At high pressures, this can lead to a rupture of the aorta, which can be fatal. It is part of the acute aortic syndromean umbrella term for aortic dissection, intramural haematoma, and symptomatic aortic ulcer table. Percutaneous treatment for patients with type b ad. Diagnosis and management of aortic dissection bja education. Aortic dissection management and treatment cleveland clinic. An aortic dissection is a tear that occurs between the innermost and middle layers of the aorta.
Aortic dissection occurs when a tear occurs in the inner muscle wall lining of the aorta, allowing blood to split apart the muscle layers of the aortic wall symptoms of aortic dissection include a tearing or ripping pain in the chest, sweating, nausea, shortness of breath, weakness, or syncope. In the diagnostic algorithm, having one or more element of any of the high risk categories gives you one point for that category. Aortic dissection is a relatively rare but highly lethal disease. Acute aortic dissection is defined as dissection occurring within 2 weeks of onset of pain. Aortic dissection knowledge for medical students and.
Aortic dissection is the surging of blood through a tear in the aortic intima with separation of the intima and media and creation of a false lumen channel. Dec 15, 2019 cardiac tamponade is a leading cause of death in aortic dissection patients. The estimated incidence is 530 cases per million people per year. Web addenda all web figures and web tables are available in. There were no pulmonary abnormalities to be noticed clinically or on this scan. An aortic dissection is a tear in the inner layer of the aortic wall, which allows blood to enter into the wall of the aorta, creating a new passage for blood, known as the false lumen. It can rob crucial blood from the rest of the body, it can cause the dissection to spread and. You may need at least 1 month to recover from your aortic dissection repair surgery. Less blood leaves the heart, and it leaves with less force. Surviving aortic dissection and navigating its aftermath. Aortic dissection is caused by an intimal and medial tear in the aorta with propagation of a false lumen within the aortic media. Treatment goals of tevar in aortic dissection include coverage of the primary entry tear and optimization of. Aortic root and aortic valve involvement are reported in up to 80% of patients.
Aortic dissection causes, symptoms, and treatment upmc. Initial evaluation and management of acute thoracic aortic. Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. Aortic dissection diagnosis and treatment mayo clinic. Blood then surges through the tear, causing the inner and middle layers of the aorta to separate dissect. Beta blockers are often the first treatment for a type b aortic dissection. This potentially lifethreatening condition occurs in roughly two out of every 10,000 people at upmc, experts from either the department of cardiothoracic surgery or the division of vascular surgery will handle the treatment of your dissecting aortic aneurysm.
Although open surgery is the main treatment for proximal aortic repair. Acute aortic dissection can be treated surgically or medically. It usually requires urgent surgery to repair or replace the first segment of. If you have symptoms of aortic dissection, severe chest pain, symptoms of stroke, call 911 or seek. Through a median sternotomy, the involved aortic segment ascending aorta and aortic.
Since morgagnis first comprehensive description in 1761, aortic dissection has challenged us as to find an appropriate management. An aortic dissection is a tear in the inner layer of the aorta which leads to a progressively growing hematoma between in the intimamedia space. Management of acute aortic dissection and thoracic aortic rupture. An aneurysm is a bulge or ballooning in the wall of an artery. Aortic dissection is the most devastating complication of thoracic aortic disease.
Hypertensive emergency in aortic dissection and thoracic. The debakey system is classified into three types types i, ii. In fact, prior analysis suggests that patients with painless dissection have a heightened risk. Aortic dissection is a serious and sometimes fatal condition, but the experts in our complex aortic center are helping more people live long and healthy lives. Aortic dissection is a lifethreatening condition and needs to be treated right away. Despite improvement in surgical techniques and advances in perioperative care, the operative mortality and morbidity for complicated acute type b aortic dissection remains high. Guidelines for diagnosis and treatment of aortic aneurysm and. Risk factors for aortic dissection include aortic coarctation, blunt trauma, connective tissue disorder. Medical management consists of decreasing the blood pressure and the shearing forces of myocardial contractility in order to decrease the intimal tear and propagation of the dissection. As a result of substantial advances in diagnostic modalities, treatment strategies, and their relative impact on early and late outcomes, the european society of cardiology esc guidelines have recently suggested to further divide the time course of aortic dissection into acute 90 days phases. Aortic dissection is defined as a separation of the layers of the aortic wall due to an intimal tear.
Endovascular approach has been proposed as a potential alternative. Followup of patients after intervention for abdominal aortic aneurysm. Debakey developed aortic dissection himself at age 97 in 2005, and underwent surgery in 2006. When this inner lining tears, blood escapes from the lumen of the aorta, where blood usually flows, into the lining.
Hypertensive males between the 4 th and 6 th decade have the highest incidence of aortic dissection. Jan 08, 2019 aortic dissection see the image below is defined as separation of the layers within the aortic wall. The goal of the aortic dissection repair surgery is to replacerepair the affected aorta. Correlates of delayed recognition and treatment of acute type. It usually requires urgent surgery to repair or replace the first segment of the aorta ascending aorta where the tear started. Dissection most commonly occurs with a discrete intimal tear, but can occur without one. Pdf acute aortic dissection is one of the most rapidly fatal clinical entities that can be encountered in the emergency department setting. The reported shortterm 30day or inhospital mortality for type a acute aortic dissection is 17% median 14% for open surgical procedure and 016% median 7% for thoracic endovascular aortic repair tevar. Acute medical management of acute aortic syndromes including aortic dissection involves controlling pain, and providing antiimpulse therapy in the form of blood pressure lowering and decreasing the velocity of left ventricular contraction, to decrease aortic shear stress and minimize the tendency for the dissection to propagate. An aortic dissection is a medical emergency requiring immediate treatment.
Acute aortic dissection comprises the majority of acute aortic syndromes. Stable ii clinical trial on endovascular treatment of acute. Used almost synonymously with dissection without a tear from the pathological viewpoint or noncommunicating aortic dissection from the clin ical viewpoint. Having an aneurysm increases the risk of rupture or an aortic dissection a tear in the lining of the aorta, shown in the image on the right. Aortic dissection has been estimated to have an incidence of 3100,000 per year 4,5. Ritter rules are a compilation of reminders, symptoms, and risk factors designed to prevent the misdiagnosis of thoracic aortic dissection. Other risk factors include age, male sex, smoking, preexisting aortic diseases or aortic valve disease, family history of aortic diseases, history of cardiac surgery, direct blunt trauma, and the use of intravenous drugs such as cocaine or amphetamines 1. Aortic dissection symptoms, diagnosis and treatment. Treatment recommended for some patients in selected patient group.
Pathophysiology and surgical treatment of type a acute aortic. Midterm results of endovascular treatment of complicated acute type b aortic dissection background. For untreated acute dissection of the ascending aorta, the mortality rate is 12% per hour early after symptom onset. Presented at the 2016 vascular annual meeting of the society for vascular surgery, national harbor, md, june 811, 2016. An aortic aneurysm occurs when a weak spot in the wall of your aorta begins to bulge left. This type of tear is located closer to the heart and can be lifethreatening. Stable ii clinical trial on endovascular treatment of acute, complicated type b aortic dissection with a composite device design. Aortic dissection columbia university department of surgery. The two main complications are rupture, when the aorta bursts and causes serious internal bleeding, or malperfusion, reduced blood flow to. Synonymous with noncommunicating aortic dissection. In the more than 250 years since thoracic aortic dissection was first described, much has been learned about diseases of the thoracic aorta.
Aortic dissection an overview sciencedirect topics. The dissection may occur anywhere along the aorta and extend proximally or distally into other arteries. If an aneurysm grows large, it can burst and cause dangerous bleeding or even death. Note the continued decreasing survival up to 30 days after presentation in what has been traditionally considered the chronic phase of aortic dissection. Acute aortic dissection is the most common lifethreatening disorder affecting the aorta. The diagnosis and management of aortic dissection the bmj.
Cardiac tamponade is a leading cause of death in aortic dissection patients. Aortic dissection repair surgerytypesrecovery period. Aortic dissection is a tear in the inner layer of the aorta the major artery carrying blood out of the heart. Treatment for a thoracic aortic dissection once diagnosed, an aortic dissection should be treated quickly. Seventy percent of these patients are hypertensive and most of them are over 50 years of age, as there is reduced resistance of arterial walls with age 6,7,8. According to international guidelines, stable patients with uncomplicated type b aortic dissection tbad should receive optimal medical treatment.
Aortic dissection is a more common problem than is ruptured abdominal aortic aneurysm. Blood flow into the false lumen can cause several problems. Aortic dissections occur in approximately 3 per 100,000 patients per year. Update in the management of type b aortic dissection. Pathophysiology, diagnosis, and management of aortic dissection.
In the more than 250 years since thoracic aortic dissection was. Arteries are blood vessels that carry oxygenrich blood from the heart to other parts of the body. Dissections that occur in the part of the aorta that is leaving the heart ascending are treated with surgery. There is controversy on performing a pericardiocentesis in aortic dissection patients with hemopericadium concern that performing this procudere would dislodge a clot and worsen leak from aorta into pericardium. Because aortic dissection is a lifethreatening condition, treatment is typically needed immediately. Subacute and chronic dissections occur between 2 and 6 weeks, and more than 6 weeks from the onset of pain, respectively. Aortic dissection type a and b symptoms, causes, treatment.
626 274 1448 1077 1010 162 367 977 1247 1107 109 1341 627 1224 779 1221 1556 759 1357 324 342 643 42 1473 545 1143 68 1027 707 983 126 551 1298 1199 1462 259