Vascular

Aortic Dissection

PATHO

  • Tear in inner layer of aorta (tunica intima) ➔ false lumen in intima-media space ➔ hematoma

    • Blood moves down false lumen and can "re-tear" back through intima into aorta (rentry) or out adventita (BAD)

    • Vessels branching off aorta become occluded ➔ ischemia of downstream tissue

  • RF: HTN in older pts, congenital dz in younger pts (Turner, marfan) pregnancy/postpartum, stimulants, trauma

Aortic Dissection Classification

  • Stanford A: affects ascending (MC) and most at risk of rupture (↑ pressure)

    • DeBakey Type I: starts in ascending and moves to/beyond aortic arch

    • DeBakey Type II: starts and stays in ascending

  • Stanford B: doesn't affect ascending

    • DeBakey Type III: starts and stays in descending

SSX

  • Preceded by valsalva

    • Lifting heavy weight, straining on toilet...

  • Tearing pain

    • Radiating chest/back ➔ scapula

  • Hypertension ➔ dissection

  • Rupture ➔ hypotension

  • Unequal pulses/BPs

  • Occlusion of carotids ➔ syncope, confusion

  • Syncope

  • AR murmur if proximal

DX

  • CXR shows widened mediastinum

  • Bloody pericardial effusion should make spidey senses tingle

  • Stable pts: CT angiography of chest-abd-pelvis (Gold standard) or MR angiography

    • Shows double lumen, aortic dilation/hematoma, areas of ↓ perfusion

  • Unstable pts: intraoperative echo (trans-esophageal) confirms

  • D-dimer ↑ with intravascular coagulation but usage in dissection is limited

    • < 500ng/mL means they likely aren't dissecting but levels vary with sx onset

TX

  • Call an adult (surgery)

    • Immediate surgery: Stanford A (↑ risk of sudden rupture)or occlusion is causing organ damage

    • Conservative: Stanford B

      • CONTROL HTN: tx to SBP 100-120 in 20 mins (pre-op and conservative)

        • IV β-blocker first (CCB if β-blocker CI) then IV vasodilator

          • Esmolol (first) or labetalol -THEN Nitroprusside (nitroprusside first ➔ reflex tach)