Aortic dissection

Last updated: March 22, 2022

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An aortic dissection is a tear in the inner layer of the aorta that leads to a progressively growing hematoma in the intima-media space. Risk factors for aortic dissection include age and hypertension. Patients typically present with sudden onset severe pain radiating into the chest, back, or abdomen. A widened mediastinum on chest x-ray is characteristic of the diagnosis. The diagnosis is usually confirmed with CT angiogram in stable patients and transesophageal echocardiography (TEE) in unstable patients. Treatment options range from conservative measures (e.g., blood pressure optimization) to surgery (aortic stent graft), depending on the localization and severity of the dissection. Complete occlusion of branching vessels and aortic rupture are common complications. Even with treatment, mortality rates associated with aortic dissection are high.

Epidemiological data refers to the US, unless otherwise specified.

There are two classifications of aortic dissection to help direct management. Stanford classification groups dissections by whether the ascending or descending aorta is involved. DeBakey classification categorizes dissections according to their origin and extent.

Stanford classification [4]

Stanford A = Affects ascending aorta; Stanford B = Begins beyond brachiocephalic vessels

DeBakey classification (rarely used) [4]

  • Type I
  • Type II
  • Type III
    • Dissections originate in the descending aorta and most often extend distally.
    • Most cases can be managed by medical therapy.
    • Can be further subdivided into:
      • Type IIIa: limited to the descending thoracic aorta above the level of the diaphragm
      • Type IIIb: extends below the diaphragm

  • Common anatomic sites of origin
  • Transverse tear in the aortic intima (“entry”) → blood enters the media of the aorta and forms a false lumen in the intima-media space ; hematoma forms and propagates longitudinally downwards [5]
    • Rising pressure within the aortic wall → rupture
    • Occlusion of branching vessels; (e.g., coronary arteries, arteries supplying the brain, renal arteries, arteries supplying the lower limbs) ischemia in the affected areas (see “Complications” below)
    • A second intimal tear may result in a “reentry” into the primary aortic lumen.

The optimal management approach depends on the clinical presentation. Recommendations in this article are consistent with 2010 American Heart Association (AHA) guidelines, the 2014 European Society of Cardiology (ESC) guidelines, the 2015 American College of Emergency Physicians (ACEP) Clinical Policy, and the 2021 American College of Radiology (ACR) Appropriateness Criteria on acute aortic syndrome and suspected aortic dissection. [4][7][8][9][10]

Consult cardiothoracic surgery for all patients with highly suspected or confirmed aortic dissection, regardless of Stanford classification. [4]

Hemodynamically unstable patients [4][7][11][12]

Patients may present with shock or cardiac arrest due to complications of aortic dissection, e.g., aortic rupture, acute coronary syndrome, cardiac tamponade, acute aortic regurgitation.

  • Resuscitate with ACLS and/or stabilize using ABCDE approach.
  • Perform simultaneous bedside investigations, e.g., ECG, portable CXR, and/or bedside echocardiography (TEE, TTE, or POCUS) based on availability. [8]
  • Immediately treat life-threatening complications, e.g., immediate hemodynamic support, management of cardiac tamponade.
  • Expedite surgical management.
  • Consider additional consultations: e.g., cardiology, critical care
  • Consider definitive imaging (e.g., CTA) if the patient is stabilized, in consultation with a specialist.
  • Admit to critical care unit or transfer to OR.

An initial low blood pressure reading in a limb could be falsely low due to an intimal flap obstructing its blood supply. Confirm hypotension by measuring blood pressure in a second limb. [11]

Patients with critical organ dysfunction [4][7][11][12]

Aortic dissection can present as a mimic of another time-dependent life-threatening condition, e.g., ACS, CVA, or pulmonary embolism.

  • Follow the management approach of the suspected condition.
    • Consider aortic dissection as a potential cause of acute ischemic stroke or STEMI
    • Rule out aortic dissection as a differential diagnosis of acute PE.
  • Evaluate prior to administering thrombolytics or other invasive therapy (e.g., PCI) if time permits.
    • Do not rely on ECG alone as findings of aortic dissection can resemble those of ACS and PE.
    • Consider portable CXR to rapidly identify classic radiographic signs of aortic dissection
    • Consider including CTA in the diagnostic evaluation to rule out aortic dissection, e.g., add CTA Chest to CTA head and neck for stroke.
    • Consider bedside TEE, TTE, or POCUS to rule in aortic dissection, if this can be done without delay. [13]
  • Treat aortic dissection if identified (see “Treatment”).

Stable patients [4][7][11][12]

Most patients (∼ 70%) with aortic dissection are stable upon initial presentation. Some may present atypically. [12]

Mortality from a type A aortic dissection increases by 1–2% per hour until management is initiated. Maintain a high level of clinical suspicion and order diagnostic studies early! [13]

Pretest probability

The following can help determine the likelihood of aortic dissection compared to other life-threatening causes with overlapping features (e.g., MI, stroke, PE).

Aortic dissection detection risk score (ADD-RS)
Risk categories Features Score if any feature present
Conditions 1
Pain characteristics
  • Chest, back, or abdominal pain with:
    • Abrupt onset
    • Severe intensity
    • Ripping or tearing
1
Examination findings 1
Interpretation
  • Score 2–3 (high risk): Expedite definitive imaging.
  • Score 0–1 (low or moderate risk): diagnostic workup (e.g., ECG, laboratory studies, and chest x-ray) as clinically indicated

Approach [4][7][9][10]

The optimal diagnostic approach depends on each individual's pretest probability, clinical presentation, and risk profile (see “Management”).

  • Order ECG for all patients.
  • Order laboratory studies (consider including D-dimer). [8]
  • CXR, TTE, and POCUS are considered screening imaging and are usually only obtained as the initial study if:
    • Invasive or risky testing is not desired for low-risk patients.
    • Definitive imaging is not readily available.
    • Patients are too unstable to undergo definitive imaging. [13][16]
  • Definitive imaging includes CTA (gold standard), TEE, and MRA and should be obtained as the:
    • Initial study for high-risk patients
    • Confirmatory study if the diagnosis remains uncertain

Definitive imaging can determine the type of lumen, location, and extent of the dissecting membrane. The identification of a false lumen on imaging is highly suggestive of aortic dissection.

D-dimer, CXR, TTE, and POCUS are not sensitive enough to reliably rule out aortic dissection. [8]

Imaging for aortic dissection [4][7][9][10]
Modalities Advantages Disadvantages
CXR
  • Rapid; can be performed at the bedside
  • Readily available, noninvasive, low level of radiation
  • Allows rapid detection of differential diagnoses, e.g. pneumothorax
  • Poorly sensitive: Normal findings do not rule out aortic dissection
Echocardiography TTE or POCUS [13][16]
  • Requires trained clinicians
  • Operator-dependent
  • Views may be limited by intervening bone, air, or fat.
  • Limited sensitivity: Normal findings do not rule out aortic dissection
TEE
  • Rapid; can be performed at the bedside
  • No radiation exposure
  • High accuracy: sensitive and specific; more reliable visualization
  • Allows for quick differentiation between TAA and aortic dissection
  • May not be readily available; requires specialized expertise
  • Invasive
  • Often requires PSA for patient comfort and tolerance which can worsen hypotension [17]
  • Dissection flap can be difficult to distinguish from artifact
CTA
  • Gold standard: Very high sensitivity and specificity [4]
  • Allows for operative planning
  • Widely available
  • Radiation exposure
  • Contrast exposure
  • Cannot be performed at the bedside
MRA
Aortography (rarely performed)
  • High accuracy [9]
  • Can be performed at the bedside
  • Invasive and involves exposure to radiation and contrast
  • Requires specialized expertise
  • Does not help be exclude differential diagnoses or evaluate surrounding structures. [9]

ECG

Findings are variable and include: [18]

Laboratory studies

Chest x-ray (AP view) [19][20]

Chest x-ray is often normal.

Normal chest x-ray findings do not rule out aortic dissection. If clinical suspicion for acute aortic dissection persists, perform a second imaging study.

CTA chest, abdomen, and pelvis [4]

  • Indications: stable patients, surgical planning
  • Suggestive findings
    • Intimal dissection flap
    • Double lumen
    • Aortic dilatation
    • Regions of malperfusion
    • Aortic hematoma (high-attenuation)
    • Contrast leak: indicates rupture

Magnetic resonance angiography (MRA) chest, abdomen, and pelvis

  • Indications: stable patients, contraindications to CTA
  • Suggestive findings: similar to CT angiography

Transesophageal echocardiography (TEE)

For other differential diagnosis considerations, see “Differential diagnoses of acute chest pain”.

Acute aortic occlusion [21][22]

The differential diagnoses listed here are not exhaustive.

Approach [4]

Avoid thrombolytic therapy in patients with suspected aortic dissection, e.g., for patients presenting with features of stroke or MI.

Surgical therapy [4]

Ascending aortic dissection is a surgical emergency!

Medical therapy

Hypotensive patients [4]

Avoid inotropes as they can worsen aortic wall stress.

Hypertensive patients [4]

Start beta blocker therapy before vasodilators to avoid reflex tachycardia!

Supportive care

Adequate treatment of pain and anxiety helps reduce sympathetic tone, which reduces blood pressure and heart rate, thereby lowering shear stress. [11]

All patients

Stable patients

Hypotensive patients

Hypertensive patients

  • In-hospital mortality due to aortic dissection ranges from 9 to 39%, depending on the type of dissection and treatment modality. [27][28]

We list the most important complications. The selection is not exhaustive.

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