Nontraumatic thoracic aortic dissection


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



Type A - involves ascending Aorta, +/- descending Ao (DeBakey I & II)

Type B - distal to the origin of the L subclavian a (DeBakey III)


Type I - ascending and descending Ao

Type II - isolated to ascending Ao

Type III - isolated to descending Ao

Chronic > 2wks otherwise Acute



Pain - 90% - abrupt

VasoVagal - sweat, N\V, lt headed

Neurologic Deficit - 20-40%

Syncopy - 5-10%

Physical Exam


Pulse Deficits/Discrepencies - (50% of proximal lesions but can be fleeting)

Aortic Insufficiency


Neuro - hemiplegia, parapesia, neuropathy

  • Rare - fever unknown origin


  • 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)


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.


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 


Uncomplicated Type B with aggressive medical therapy

-30 day mortality: 10%

-5 year mortality: 45-60%


Adapted from Donaldson, Bessen, Pani, DeBonis