Aortic Dissection


Acute aortic dissection (AAD) is an uncommon but dangerous condition. The aorta wall's layers separating causes aortic dissection. A rupture in the intimal layer causes the dissection to advance (either proximally or retrogradely), mostly because blood enters between the intima and media. The majority of patients who experience an abrupt aortic dissection pass away even before they get to the emergency room. Aortic dissection patients who have had it for more than two weeks have a somewhat better prognosis.

Presentations are frequently less obvious than the traditional description of a patient reporting a sudden onset of intense "tearing" chest pain.

In as few as 15% to 43% of confirmed instances of AAD, doctors properly suspect the diagnosis. In the first 48 hours after the start, mortality approaches 50% if untreated. Despite a plethora of information, the emergency room misses a large percentage of aortic dissections.

Aortic Dissection: Causes

The probable causes of aortic dissection may include −

  • 70% of individuals with distal Standford type B AAD experience hypertension.

  • A sudden, significant, brief rise in blood pressure (e.g., strenuous weight lifting and use of sympathomimetic agents such as cocaine, ecstasy, or energy drinks)

  • Marfan syndrome, Ehlers-Danlos syndrome, Turner syndrome, bicuspid aortic valve, and coarctation of the aorta are examples of genetic diseases. In an IRAD analysis, Marfan syndrome was found in 50% of individuals under the age of 40 compared to just 2% of older patients. The tissues of Marfan syndrome patients exhibit cystic medial necrosis.

  • Already present aortic aneurysm

  • Atherosclerosis

  • Birth and pregnancy (risk compounded in pregnant women with connective tissue disorders such as Marfan syndrome)

  • Family background

  • Surgery or aortic instrumentation (coronary artery bypass, aortic or mitral valve replacement, and percutaneous stenting or catheter insertion)

  • Vasculitis, causing inflammatory or infectious disorders (syphilis, cocaine use)

Aortic Dissection: Symptoms

The signs of an aortic dissection might resemble those of other cardiac conditions, such as a heart attack. Typical warning signs and symptoms are −

  • Sudden, intense chest or upper back pain that radiates to the neck or down the back and is frequently characterized as tearing or ripping

  • Acute, debilitating stomach ache

  • Consciousness loss

  • Breathlessness Stroke-like symptoms, such as abrupt visual issues, speech difficulties, and weakness or lack of movement (paralysis) on one side of the body

  • Compared to the other, one arm's or thigh's pulse is weaker

  • Leg ache

  • Having trouble walking

Aortic Dissection: Risk Factors

Your chance of an aortic dissection may be increased by several factors, such as −

  • Continually elevated blood pressure (hypertension)

  • Arteries become harder (atherosclerosis)

  • Artery that is weak and bulging (aortic aneurysm)

  • Aortic valve abnormality (bicuspid aortic valve)

  • The aorta constricting at birth (aortic coarctation)

Aortic dissection risk is increased by several hereditary disorders, such as −

  • Turner disease - This illness may lead to high blood pressure, cardiac issues, and other medical disorders.

  • Marfan disease -. Weak connective tissue, which supports numerous bodily structures, is present in this disorder. People with this illness frequently have a family history of aortic dissections or aneurysms of the aorta and other blood arteries.

  • Further connective tissue issues. This includes Loeys-Dietz syndrome, which results in twisted arteries, particularly in the neck, and Ehlers-Danlos syndrome, a collection of connective tissue illnesses characterized by loose joints and flimsy blood vessels.

Your risk of an aortic dissection may also rise if your arteries are inflamed (called giant cell arteritis).

The following are other possible aortic dissection risk factors −

  • Sex -  Aortic dissection occurs more frequently in men than in women.

  • Age - People over 60 are more prone to experience an aortic dissection.

  • Using cocaine - This medication briefly increases blood pressure.

  • Pregnancy - Aortic dissections during pregnancy are rare in otherwise healthy women.

  • Heavy lifting at a high level - By raising blood pressure while exercising, this and other intense resistance training may increase your chance of an aortic dissection.

Aortic Dissection: Diagnosis

The symptoms of an aortic dissection might make it difficult to diagnose because they are similar to many other medical conditions. Your physician could suspect an aortic dissection if you −

  • Sudden ripping or tearing pain in the chest

  • The difference in blood pressure between the right and left arms

  • Aorta widening on a chest X-ray

Aortic dissection is diagnosed by the following tests −

  • Cardiac transesophageal echography (TEE). In this test, sound waves are used to produce images of the beating heart. An ultrasound probe (transducer) is passed into your esophagus and positioned close to your heart during a TEE, a specific kind of echocardiography. Compared to a standard echocardiogram, this test offers your doctor a more detailed view of your heart and aorta.

  • Chest-based computerized tomography (CT) scan. Images of the body's cross-section are created using X-rays. Aortic dissection can be diagnosed with a chest CT.

  • Angiogram using magnetic resonance (MRA). A magnetic field and radio wave radiation are used in an MRA to produce pictures of your blood arteries.

Aortic Dissection: Treatment

Aortic dissection is a medical emergency that has to be treated right away. Depending on the section of the aorta affected, the course of treatment may require surgery or medication.

Surgery

To prevent blood from seeping into the aortic wall, surgeons cut off as much of the dissected aorta as they can. The aorta is rebuilt using a synthetic tube (transplant). The aortic valve can be replaced concurrently if it leaks due to the injured aorta. The graft is then filled with the replacement valve.

Medications

Blood pressure and heart rate are lowered with medication, which can stop the aortic dissection from getting worse. Before surgery, they may be administered to persons with type A aortic dissection to lower blood pressure.

Aortic Dissection: Prevention

Aortic dissection risk can be decreased by guarding against chest injuries and maintaining a healthy heart.

  • In charge of blood pressure - If you have high blood pressure, invest in a home blood pressure monitor to help you keep track of it.

  • Avoid smoking - If you already smoke, take action to quit.

  • Keep your desired weight. Maintain a low-sodium diet rich in fruits, vegetables, and whole grains, as well as regular exercise.

  • Put on your seatbelt - This lessens the chance of suffering a chest injury in a car collision.

  • Consult your physician - Tell your doctor if you have a connective tissue problem, a bicuspid aortic valve, or a family history of aortic dissection. Learn how often you must be monitored if you have an aortic aneurysm and whether surgery is required to treat it.

Even if your blood pressure is within normal range, your doctor may advise drugs if you have a hereditary disease that raises your chance of aortic dissection.

Conclusion

If left untreated, aortic dissection is a serious medical emergency with a very high fatality rate. Since most patients arrive at the emergency room, an interprofessional team is essential.

A consistent protocol must be in place once the patient with an aortic dissection arrives at the emergency room to guarantee that the diagnosis and treatment are completed right away. An ECHO or a CT scan are the two choices.

For a bedside echo, a cardiologist should be consulted. There is an immediate need to reduce blood pressure, and the intensivist should be informed. When a patient with a dissection is admitted, the operating room has to be informed. To improve results, the team's members must be able to communicate openly.

Dr. Durgesh Kumar Sinha
Dr. Durgesh Kumar Sinha

MBBS MS [ OPHTHALMOLOGY ]

Updated on: 03-Mar-2023

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