Nontraumatic thoracic aortic dissection

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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