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Acute Aortic Dissection

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

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  1. Acute Aortic Dissection AM Report 6/29/09 Brandon M. Williams, MD

  2. Classification • Two systems: • DeBakey • Daily (Stanford) = most used

  3. 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)

  4. Daily (Stanford) • Type A: involves ascending aorta • Type B: all others - Nomenclature doesn’t change secondary to site of origin

  5. Daily (Stanford)

  6. 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

  7. Incidence • Acute aortic dissection - 2.6-3.5/100,000 person years

  8. Incidence • Classic is 60 – 80 yo males (mean 63yo) • Women 67 • Ascending 2x more likely than descending, with right lateral wall most common site

  9. Risk Factors • 13% with known aortic aneurysm (19% if < 40yo) • Inflammatory disease vasculitis -giant cell arteritis -takayasu arteritis -rheumatoid arthritis -syphilitic aortitis

  10. 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

  11. 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

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  16. Diagnosis • Abrupt onset of pain, tearing/ripping • Mediastinal/aortic widening on Chest X ray • Variation in pulse

  17. Imaging • Chest Xray • TTE • TEE • CTA chest • MRI • Coronary angiography

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  21. 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

  22. 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

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