Skip to Main Content

++

  • Acute aortic dissection occurs more commonly than ruptured abdominal aortic aneurysm.
  • The typical pain, poor peripheral perfusion, and evidence of aortic branch occlusion suggest the diagnosis.
  • Early pharmacologic control of systolic blood pressure and the pulse wave (dP/dT) is imperative.
  • Investigations must be undertaken urgently to confirm the diagnosis and direct definitive treatment.
  • Emergency surgical repair is indicated for type A dissections.
  • Control of hypertension is important to minimize complications and maximize survival both in the postoperative period and in the long term.
  • Type B dissections may have a more ominous prognosis than previously thought and require very close long-term follow-up.

++

Aortic dissection is the most common catastrophe affecting the aorta, occurring two to three times more commonly than acute abdominal aortic aneurysm rupture.1 The reported incidence is approximately 10 to 20 per 1 million per year.2 Rarely is the outcome of a cardiovascular disease so dependent on the skills and cooperation of the emergency room physician, the cardiac surgeon, and the intensivist as it is with acute dissections of the aorta. Maximal survival depends on a high index of suspicion of the diagnosis despite a myriad of different presentations, early pharmacologic intervention for control of hypertension, rapid diagnosis with definitive imaging, and then appropriate relegation to medical or surgical management depending on the dissection type. Without treatment, the 3-month mortality is 85% to 90%, but with the appropriate treatment, survival rates of over 80% can be expected.

++

Previously, aortic dissections were referred to as dissecting aneurysms, as originally coined by Laënnec. This is a misnomer in that the pathology is a dissecting hematoma that separates the intima and inner layers of the media from the outer medial and adventitial layers (Fig. 30-1). The intima is therefore not aneurysmal, and is if anything, narrowed. Blood invades the media through a tear in the intima and proceeds ante- or retrogradely through the aortic wall, forming a false lumen. The hematoma spirals around the right and posterior aspects of the ascending aorta, supraposteriorly along the arch, and then down the left and posterior aspects of the descending aorta.3 The hematoma may then have several serious sequelae. It may rupture into the pericardial space causing tamponade, or into the pleural space with exsanguinating hemorrhage. This occurs less frequently than expected because the adventitial layer represents 66% of the overall strength of the aortic wall. It may also cause occlusion of aortic branch arteries or prolapse of one or more of the aortic valve cusps, resulting in acute aortic insufficiency.

++
Figure 30–1.
Graphic Jump Location

Aortic dissection begins with an intimal tear (1) leading to a hematoma that separates the layers of the aortic wall. The sequelae are rupture through the adventitia into the pericardium (2), prolapse of the aortic valve cusps leading to aortic insufficiency (3), compression of the aortic ...

Want remote access to your institution's subscription?

Sign in to your MyAccess profile while you are actively authenticated on this site via your institution (you will be able to verify this by looking at the top right corner of the screen - if you see your institution's name, you are authenticated). Once logged in to your MyAccess profile, you will be able to access your institution's subscription for 90 days from any location. You must be logged in while authenticated at least once every 90 days to maintain this remote access.

Ok

Create a Free MyAccess Profile

* Required Fields

Note: If you have registered for a MyAccess profile on any of the Access sites, you can use the same MyAccess login credentials across all sites.

Passwords must be between 6 and 40 characters long (no whitespace), cannot contain characters #, &, and must contain:
  • at least one lowercase letter
  • at least one uppercase letter
  • at least one digit

Benefits of a MyAccess Profile:

  • Remote access to the site off-campus on any device
  • Notification of new content via custom alerts
  • Bookmark your favorite content such as chapters, figures, tables, videos, cases and more
  • Save and download images to PowerPoint
  • Self-Assessment quizzes saved for quick review
  • Custom Curriculum access for both instructors and learners

Subscription Options

AccessAnesthesiology Full Site: One-Year Subscription

Connect to the full suite of AccessAnesthesiology content and resources including procedural videos, interactive self-assessment, real-life cases, 20+ textbooks, and more

$995 USD
Buy Now

Pay Per View: Timed Access to all of AccessAnesthesiology

24 Hour Subscription $34.95

Buy Now

48 Hour Subscription $54.95

Buy Now

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.