Nontraumatic thoracic aortic dissection: Difference between revisions
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==Background== | ==Background== | ||
2-3x > men usually 50-70 yrs old | 2-3x > men usually 50-70 yrs old | ||
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Predisposing factors: Marfans, Ehlers-Danlos, congenital heart dz, pregnancy (third trimester), bicuspid valve (9x), cocaine, decelerating trauma, aortitis (syphilis, Takayasu, giant cell) | Predisposing factors: Marfans, Ehlers-Danlos, congenital heart dz, pregnancy (third trimester), bicuspid valve (9x), cocaine, decelerating trauma, aortitis (syphilis, Takayasu, giant cell) | ||
RISK FACTOR: Hypertension >>> smoking, cocaine, dyslipidemia | RISK FACTOR: Hypertension >>> smoking, cocaine, dyslipidemia | ||
===Classification=== | ===Classification=== | ||
Stanford: | Stanford: | ||
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Type B - distal to the origin of the L subclavian a (DeBakey III) | Type B - distal to the origin of the L subclavian a (DeBakey III) | ||
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Type III - isolated to descending Ao | Type III - isolated to descending Ao | ||
Chronic > 2wks otherwise Acute | Chronic > 2wks otherwise Acute | ||
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===History=== | ===History=== | ||
Pain - 90% - abrupt | Pain - 90% - abrupt | ||
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Syncopy - 5-10% | Syncopy - 5-10% | ||
===Physical Exam=== | ===Physical Exam=== | ||
Tachycardia | Tachycardia | ||
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*Rare - fever unknown origin | *Rare - fever unknown origin | ||
===Studies=== | ===Studies=== | ||
*D-Dimer always elevated (sensitive but not specific) | *D-Dimer always elevated (sensitive but not specific) | ||
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Aortography (S/S 94/88) | Aortography (S/S 94/88) | ||
==Treatment== | ==Treatment== | ||
Keep BP 100-120sys, HR 60-80 | Keep BP 100-120sys, HR 60-80 | ||
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2. Type B - Medical, unless uncontrolled BP, Cont Pain, Rupture. | 2. Type B - Medical, unless uncontrolled BP, Cont Pain, Rupture. | ||
==Complications== | ==Complications== | ||
1 Rupture | 1 Rupture | ||
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pericardium --> tamponade | pericardium --> tamponade | ||
mediastinum --> hemothorax | mediastinum --> hemothorax | ||
2 Obstruction of branch vessels | 2 Obstruction of branch vessels | ||
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mesenteric, renal, or limb ischemia | mesenteric, renal, or limb ischemia | ||
3 AV Insufficiency | 3 AV Insufficiency | ||
diastolic murmur and CHF | diastolic murmur and CHF | ||
==Prognosis== | ==Prognosis== | ||
Uncomplicated Type B with aggressive medical therapy | Uncomplicated Type B with aggressive medical therapy | ||
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-5 year mortality: 45-60% | -5 year mortality: 45-60% | ||
==Source== | |||
==Source == | |||
Adapted from Donaldson, Bessen, Pani, DeBonis | Adapted from Donaldson, Bessen, Pani, DeBonis | ||
[[Category:Cards]] | [[Category:Cards]] | ||
Revision as of 07:28, 3 March 2011
Background
2-3x > men usually 50-70 yrs old
Predisposing factors: Marfans, Ehlers-Danlos, congenital heart dz, pregnancy (third trimester), bicuspid valve (9x), cocaine, decelerating trauma, aortitis (syphilis, Takayasu, giant cell)
RISK FACTOR: Hypertension >>> smoking, cocaine, dyslipidemia
Classification
Stanford:
Type A - involves ascending Aorta, +/- descending Ao (DeBakey I & II)
Type B - distal to the origin of the L subclavian a (DeBakey III)
DeBakey:
Type I - ascending and descending Ao
Type II - isolated to ascending Ao
Type III - isolated to descending Ao
Chronic > 2wks otherwise Acute
Diagnosis
History
Pain - 90% - abrupt
VasoVagal - sweat, N\V, lt headed
Neurologic Deficit - 20-40%
Syncopy - 5-10%
Physical Exam
Tachycardia
Pulse Deficits/Discrepencies - (50% of proximal lesions but can be fleeting)
Aortic Insufficiency
Tamponade
Neuro - hemiplegia, parapesia, neuropathy
- Rare - fever unknown origin
Studies
- D-Dimer always elevated (sensitive but not specific)
ECG - Vent. hypertrophy from HTN, 10-40% may show ischemia or infarction, 33% normal
CXR - 60-90% mediastinal widening (S/S 67/70), double shadow, aortic knob, CA+ sign rare but specific, pleural effusions
Echo (TEE) (S/S 97-100/90-100)
CT & MRI - 95%
Aortography (S/S 94/88)
Treatment
Keep BP 100-120sys, HR 60-80
1. Nitroprusside (0.5-1.0mcg/kg/min; titrate) & B-blocker eg esmolol (0.5mg/kg loading, 0.05mg/kg/min infusion; titrate)
2. Labetalol (10-20mg IV q10mins, or initial infusion rate at 2mg/min; titrate) or
3. Verapamil
1. Type A - Surgery, unless worsening stroke
2. Type B - Medical, unless uncontrolled BP, Cont Pain, Rupture.
Complications
1 Rupture
pericardium --> tamponade
mediastinum --> hemothorax
2 Obstruction of branch vessels
coronaries --> acute MI
arch vessels --> stroke
lumbar --> paraplegia
mesenteric, renal, or limb ischemia
3 AV Insufficiency
diastolic murmur and CHF
Prognosis
Uncomplicated Type B with aggressive medical therapy
-30 day mortality: 10%
-5 year mortality: 45-60%
Source
Adapted from Donaldson, Bessen, Pani, DeBonis