Acute aortic dissection

1. Acute Aortic
Syndrome
Atypical presentation of a
typical case

2. The life you wanted to live
May be buried under what you won
Don't linger and longer
Let us walk & have some fun

3. DEFINATION
A separation of the layers of the aortic wall by
an inciting intimal injury

4. RIHGT
BORDER OF
ASCENDING
AORTA
WHERE THE DP/DT IS THE
HIGHEST

5. FIXED OBSTRUCTION

6. DYNAMIC OBSTRUCTION

7. PATHOLOGY
 55 to 65% of aortic intimal tears originate in the
ascending aorta within the sinotubular junction and
extend to involve remaining portions of the
thoracoabdominal aorta
 20 to 30 percent of intimal tears will originate in the
vicinity of the left subclavian artery and extend into
the descending thoracic and thoracoabdominal
aorta
 Related to shear forces (dP/dT) being highest in
these regions

8.  Aortic arch involvement is seen in up to 30 percent
 Aortic intramural hematoma more commonly involves the descending aorta
 Most penetrating aortic ulcers are located in the descending thoracic aorta (85 to
95 percent), but they can also occur in the ascending aorta or arch

9. Variants
Intimal tear without hematoma
Penetrating aortic ulcer
Aortic intramural hematoma
Periaortic hematoma

10. RISK FACTORS
GENETIC
 Hypertension
 Atherosclerosis
 Prior cardiac surgery
 Aneurysm
 TRAUMA
 Penetrating aortic ulcers account for
2 to 7[ATHEROSCLEROTIC ]
ACQUIRED
 Marfan syndrome
 Loeys-Dietz syndrome

11. CAUSES
Spontaneous
IATROGENIC
TRAUMATIC
Aortic intramural hematoma
Intimal tear without hematoma
Penetrating aortic ulcer
Periaortic hematoma

12. PATHOLOGICAL TYPES

13. Natural
history
Aortic dissection is a more common than abdominal aortic
2-4/100000
M:F=5:1
Type B patients are 10 years older than type A
Age : 60 and 70 years
HTN in 75%
Pain is the most common presenting symptom in 95% and sudden

14.  Acute aortic dissection is highly lethal if not recognized and treated aggressively
 20% die before reaching the hospital
 Mortality for an untreated dissection is about 25% at 6 hours and 50% by 24
hours. Within 1 week, two thirds of patients die if untreated and 75% occur in the
first 2 weeks
 Acute dissection <14 days
 chronic dissections surviving more than 2 weeks
 The rule of thumb has been a mortality of 1% per hour in the acute stage
 2 independent risk factors most often identified :HTN and AGE

15. type A
 treated medically have a mortality of 58%
 mortality for surgical treatment of type A dissections is 26%
 Immediately life-threatening problem than is type B
 Die of pericardial tamponade, rupture, aortic valve dysfunction, or malperfusion of
the coronary arteries. Patients who present with syncope are more likely to have a
type A dissection than a type B; syncope is associated with cardiac tamponade,
stroke, and death

16. type B dissections
 the mortality for is initially about 10% to 12% for patients who can be treated
medically
 Surgical or endovascular therapy is indicated for complications including
progressive pain and dissection extension, rupture, and compromise of limb or
organ perfusion
 Patients with such complications necessitating intervention have a higher mortality
of at least 30%

17. FROM ONSET OF PRESENTATION
 Hyperacute: <24 hours
 Acute: 1 to 14 days
 Subacute: >14 to 90 days
 Chronic: >90 days

18. PRESENTATION
 Symptoms
 acute onset of severe chest or back pain : 80 to 90% , severe, sharp, or "tearing" and is
located in the anterior chest pain for type A aortic dissection and in the posterior chest or
back pain for type B aortic dissection
 Signs
 Asymmetric limb pulses
 shock, syncope, acute congestive heart failure, myocardial ischemia, stroke, paraplegia,
extremity ischemia, mesenteric ischemia)
 Aortic regurgitation
 Pericardial effusion
 Acute coronary syndrome

20. Clinical
Triad
Abrupt onset of thoracic or
abdominal pain with a
sharp, tearing, and/or
ripping character
01
A variation in pulse
(absence of a proximal
extremity or carotid pulse)
and/or blood pressure (>20
mmHg difference between
the right and left arm)
02
Mediastinal and/or aortic
widening on chest
radiograph
03

21. Differential diagnosis
 acute coronary syndrome
 pulmonary embolus
 spontaneous pneumothorax
 aortic regurgitation without dissection
 oesophageal rupture
 pericarditis
 pleuritis

22. DX HX CE ECG X-RAY Test Remark
Aortic
dissecti
on
Pain HTN
PULSELES
S
NORMAL WIDE
MEDIASTI
TROP-
DIMER+
CECT+
ACS PAIN CHF ACS PULM OE TROP+ ECHO+
PE PAIN RHF S1Q3T3 PAH DIMER+ DVT+
Tension
pneumo
thorax
SOB
PAIN
DIMINISH
ED BS
NORMAL PNEUMO CECT+
tampon
ade
SOB
SHOCK
BECK’S
TRIAD
ELECALT BOTTLE
HEART
CECT+
Mediasti
nitis
WIDE
MEDIA
CECT+
Oesoph
ageal
rupture
DYSPHAGIA
PAIN
Hamman's
crunch
NORMAL CECT+

23. INVESTIGATIONS
 ECG. Look for signs of ACS; extension of type A dissection to coronary ostia can
cause coronary ischemia (right coronary artery most commonly affected).
 D-dimer, CBC, basic electrolytes, LDH, cardiac markers, coagulation parameters,
and type and crossmatch. D-dimer <500 ng/dL is less likely to be aortic dissection.
 X-RAY: Widened mediastinum and/or unexplained pleural effusion are consistent
with dissection, particularly if unilateral.

24. Vascular imaging
 Stable without suspicion for ascending aortic involvement: Obtain thoracic CT
angiography or MR angiography, depending upon resources and speed of
acquisition. Dissection is confirmed by presence of intimal flap separating true and
false lumen. If these are not readily available or there is a contraindication, obtain
transesophageal echocardiogram.
 Unstable patient or for strong suspicion of ascending aortic involvement:
Obtain transesophageal echocardiogram. If not immediately available, obtain CT
angiography. Transthoracic echocardiography may be useful for identifying
complications of ascending aortic dissection (eg, aortic valve regurgitation,
hemopericardium, inferior ischemia) but is not sensitive for identification of
dissection.

25. MANAGEMENT
 Controlling pain
 Anti-impulse therapy by controlling the blood pressure to minimize the likelihood
of rupture or progression, unless hypotension is present
 IMMEDIATE TRANSFER CTVS FOR SURGERY or endovascular intervention or either

26. HR ≤60/BPM
 Place two large bore Ivs
 Monitor heart rate and blood pressure [arterial line]
 Control heart rate <60 BPM
 Esmolol :250 to 500 mcg/kg IV loading dose, then infuse at 25 to 50 mcg/kg/minute;
titrate to maximum dose of 300 mcg/kg/minute)
 Labetolol (20 mg IV initially, followed by either 20 to 80 mg IV boluses every 10 minutes
to a maximal dose of 300 mg, or an infusion of 0.5 to 2 mg/minute IV)
 Beta blockers are not tolerated, alternatives are verapamil, diltiazem, or nicardipine.

27. SBP:100 and 120 mmHg
 Once heart rate is consistently <60 BPM, give vasodilator therapy
 IF SBP >120 mmHg, initiate nitroprusside infusion (0.25 to 0.5 mcg/kg/minute titrated to
a maximum of 10 mcg/kg/minute) or nicardipine infusion (2.5 to 5 mg/hour titrated to a
maximum of 15 mg/hour)
 Vasodilator therapy (eg, nitroprusside, nicardipine) should not be used without first
controlling heart rate with beta blockade.

28. REDUCE PAIN
 Give IV opioids for analgesia (eg, fentanyl).
 Place Foley catheter for assessment of urine output and kidney perfusion.

29. CTVS CONSULTATION
 Aortic dissection involving the ascending aorta is a cardiac surgical emergency
 Aortic dissection involving only the descending thoracic aorta or abdominal aorta
and with evidence of malperfusion is treated with urgent aortic stent-grafting or
surgery.
 Aortic dissection involving only the descending thoracic aorta or abdominal aorta
without evidence for ischemia is admitted to the ICU for medical management of
hemodynamics and serial aortic imaging.
 If appropriate surgical services◊ are not available, initiate emergent transfer to
nearest available cardiovascular center.

30. The grand round :Checklist of a case
 CHIEF COMPLAIN
 PRESENTATION
 PAST HISTORY
 TREATMENT HISTORY
 PERSONAL HISTORY
 PROFESSIONAL HISTORY
 FAMILY HISTORY

31. Checklist of a case presentation
 GENERAL PHYSICAL EXAMINATION
 SYSTEMIC EXAMIATION
 CARDIOVASCULAR
 OTHERS
 SUMMERY
 DIFFERENTIAL DIAGNOSIS
 FINAL DIAGNOSIS
 TREATMENT OPTIONS

32. CASE VIGNETTE
55YRS OLD/F
HTN - 2YRS ON AMLODIPINE 5MG OD
NO DM
EUTHYROID

33. CHIEF COMPLAIN
 CHEST PAIN FOR 48HRS

34. PRESENT ILLNESS
 SHE IS A KNOWN CASE OF HYPERTENSION ON REGULAR AMLODINE 5MG DAILY FOR LAST 2YRS
 CHEST PAIN
 48HRS
 STARTED AT 11AM
 DURING A BUCKET OF WASHED CLOTHES TO THE TERRACE
 CONFINED TO MID CHEST
 ANXIOUS
 BREATHLESS AT REST
 SWEATING PRESENT
 NO RADIATION
 NO RESPIRATORY VARIATION
 NOT RELIVED BY ANTACID OR SUBLINGUAL NITRATE
 TRANSIENT RELIEF USING INTRAVENOUS OPOID ANALGESIC

35. CLINICAL EXAMINATION
 ANXIOUS
 BP=190/120
 NO PULSE DEFICIT
 NO BRUIT

36. Differentiation of life-threatening causes of
chest pain
 Acute coronary syndrome

38. FOLLOW UP ECG

39. TROPONIN I TEST
 NEGATIVE
 D-dimer > 500 mcg/L

40. Widened mediastinum

41. TRANSTHORACIC ECHOCARDIOGRAGHY
 GOOD BV FUNCTION
 VALVES ARE NORMAL
 NO PERICARDIAL EFFUSION
 EVIDENCE OF AORTIC DISSECTION ?

42. TRANSESOPHAGIAL ECHOCARDIOGRAGHY
 AORTIC DISSECTION OF ARCH OF AORTA AND DESCENDING THORACIC AORTA
with possible entry point in the arch of aorta

43. Computed tomographic (CT) angiography

45. REFERED AIIMS NEW DELHI IN <24HRS
 STABLISED WITH HEART RATE REDUCTION ,BP CONTROL AND PAIN REDUCTION
 PATIENT WAS TREATED WITH SURGERY