No one is expecting, moment-to-moment, to develop an acute Aortic dissection, but everyone who has experienced one knows exactly when it occurred. Most patients with acute Aortic dissections describe a tearing, burning pain located in the front of their chest or in their back midway between the shoulder blades. The intensity and suddenness of the pain usually brings people to their knees (or they pass out). Unfortunately, may people who experience an acute Aortic dissection die on the spot.
According to the International Registry of Acute Aortic Dissection:
Approximately 2000 new cases are reported every year in the United States. It is a rare but serious condition that mostly occurs in men aged 60 to 80. However, the male-to-female ratio is 3:1 and aortic dissections do occur in young people, especially those with risk factors.
The Stanford Classification system divides patients with Aortic dissection into two categories, Type A and B. In Type A dissection patients, the entry tear of the Aortic dissection begins in the ascending aorta (close to the heart). In Type B Aortic dissection patients, the entry tear of the Aortic dissection begins in the descending thoracic aorta beyond the left subclavian artery. The management of these patients differs. Acute Type A Aortic dissection patients require emergency open heart surgery. The severity of the situation is increased because of the location of the tear being close to the heart. The survival of these patients depends on prompt surgical intervention. There is the risk of pericardial tamponade (blood around the heart), acute insufficiency of the aortic valve, stroke from lack of blood to the brain, and malperfusion to the organs and/or extremities. Obviously, this is a life and death situation can best be treated with surgical repair of the ascending aorta. The goal is to surgically remove the start of the tear (entry tear) and replace the affected aortic segment with a prosthetic surgical graft. We will be discussing the various types of surgical repairs, including aortic root replacement, ascending aortic replacement, Bentall procedures, hemiarch procedures and valve-sparring root procedures. Aortic dissections may be associated with aortic aneurysms, but not always.
With acute Type B Aortic dissections, the management is different. The two most common forms of treatment are optimal medical therapy versus endovascular stent-graft repair (TEVAR). In future posts, we will discuss the indications for each of those options. Nevertheless, the management of acute Aortic dissections depends on a number of different variables, but it starts with whether the dissection is a Type A or Type B.
As stated above, many patients with acute Aortic dissections never make it to the hospital. That is usually because the aorta ruptures. This means that the tearing of the aorta is so significant that the integrity of the aortic wall gives way and there is massive, instantaneous internal bleeding. This bleeding can be so catastrophic that it is not survivable. In other cases, there is internal bleeding, but it is not so massive that the patients are not able to survive it. This type of hemorrhage is still a dire emergency, but may be “small” enough (no amount of internal bleeding is good), that the patient is able to be transported to the nearest medical center. Often, these patients need to be transferred to a tertiary hospital which has expertise in Aortic surgery and diseases (Aortic center of excellence).
In summary, acute Aortic dissections are life-threatening medical problems. Every new case of acute Aortic dissection is flirting with disaster.
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