Aortic Dissection

Dr Muhammad Burhan Pasha

MCPS, FCPS
 Arterial hypertension
 Aortic root dilatation and wall thinning
 Iatrogenic
 Aortic atherosclerosis
 Congenital aortic valve anomalies
 Marfan syndrome
 Advanced age
 Pregnancy
 Ehlers-Danlos syndrome
 Syphilitic aortitis
 Aortic arch hypoplasia
 Cocaine use
 Hypertension is a main risk factor of aortic sclerosis and
subsequent aortic aneurysm formation and aortic
dissection.
 Smoking and hypercholesterolaemia are additional risk
factors.
 15%–20% of death secondary to high speed accidents are
related to aortic trauma, frequently associated with
myocardial contusion.
 Iatrogenic aortic dissection is often related to cardiac
catheterization, angioplasty, or surgery.
 Inflammatory diseases can affect the aorta as in Takayasu
arteritis and syphilis as well as in Behcet’s disease.
 Cocaine and amphetamine associated with aortic
aneurysm formation and dissection are newly detected
aetiologies.
Types & Classification
 Aortic dissection staging
 Class 1: Classical aortic dissection with an
intimal flap between true and false lumen

 Class 2: Medial disruption with formation of

intramural haematoma/ haemorrhage

 Class 3: Discrete/subtle dissection without

haematoma, eccentric bulge at tear site
 Class 4: Plaque rupture leading to aortic
ulceration, penetrating aortic atherosclerotic
ulcer with surrounding haematoma, usually
subadventitial

 Class 5: Iatrogenic and traumatic dissection

 Classic aortic dissection (class 1)
 Acute aortic dissection is characterized by the
rapid development of an intimal flap separating
the true and false lumen

 The dissection can spread from diseased

segments of the aortic wall in an antegrade or
retrograde fashion, involving side branches and
causing other complications
 Intramural haematoma (class 2)

 Probably the initial lesion in the majority of cases

of cystic medial degeneration.
 May be the result of ruptured normal-appearing
vasa vasorum
 Can result in intimal tears
 Shows all signs of dissection
 Diffuse haemorrhagic — intramural bleeding,
giving the impression of wall thickening
 Intramural hemorrhages are found more often
in the descending aorta

 Consequences
– Aortic dissection (28-47%)
– Rupture (21-47%)
– Spontaneous resolution (10%)
Subtle-discrete aortic dissection (class 3)
 Partial stellate or linear tear of the vessel wall,
covered by thrombus

 When the partial tear forms a scar, this

constellation is called an abortive, discrete
dissection
Plaque rupture/ulceration (class 4)
 Ulceration of atherosclerotic aortic plaques can
lead to aortic dissection or aortic perforation

 Not usually associated with extensive longitudinal

propagation or branch vessel compromise

 May form intramural haematoma

 False aneurysms, aortic rupture or dissections

may occur
 Traumatic/iatrogenic aortic dissection
(class 5)
 Blunt chest trauma usually causes dissection of
the ascending aorta at the aortic isthmus
 Heart catheterization
 Angioplasty of an aortic coarctation
 Intra-aortic balloon pumping

 They will usually decrease in size as the false

lumen thromboses
 Physical Examination
 murmur of aortic regurgitation
 decrement or loss of peripheral (most commonly
one of the femoral) pulses
 difference of blood pressure in the two arms
 Signs of pericardial temponade
 Pleural effusion
 Neurological deficits
 signs of mesenteric or renal ischaemia
 Leriche’s syndrome with pulse loss in both legs
will occur, which is typically painless
Investigations/ work up
ECG
 Aortic Dissection suspected
↓
Start β- Blockers
↓
Hemodynamically stable
Yes No

MRI,TEE, CT TTE, TEE

Aortic dissection diagnosed

Type A Type B

Surgical repair CCU/med mgmt

 Surgical Treatment
 Treatment of choice for acute proximal
dissection
 Treatment for acute distal dissection
complicated by the following:
– Progression with vital organ compromise
– Rupture or impending rupture (e.g., saccular
aneurysm formation)
– Retrograde extension into the ascending aorta
– Dissection in Marfan syndrome
 Interventional techniques

 percutaneous balloon fenestration

 aortic stenting

 Branch vessel stenting

 Medical Treatment

 Treatment of choice for uncomplicated distal

dissection
 Treatment for stable, isolated arch dissection

 Treatment of choice for stable chronic

dissection (uncomplicated dissection
manifesting 2 weeks or later after onset)
 Complications
 Hypotension and shock as a result of aortic rupture and eventual
death from exsanguination
 Pericardial tamponade secondary to hemopericardium
 Acute aortic regurgitation
 Pulmonary edema secondary to acute aortic valve regurgitation
 Myocardial ischemia
 Neurologic findings due to carotid artery obstruction
 Mesenteric and renal ischemia
 Compressive symptoms, such as superior vena cava syndrome,
Horner syndrome, dysphagia, airway compromise, and hemoptysis,
Vocal cord paralysis
 Claudication - Can develop from extension of the dissection into the
iliac arteries
 Redissection and progressive aortic diameter enlargement
 Aneurysmal dilatation and saccular aneurysm