4 - Aortic Dissection

Question 1

Acute aortic syndromes are uncommon but:

Answer 1

FATAL

Question 2

Precipitating risk factors for acute aortic syndromes:

Answer 2

Chronic HTN
Congenital defects
Illicit drugs
Previous cardiac surgery 
Severe atherosclerosis

Question 3

All mechanisms of acute aortic syndromes involve:

Answer 3

Weakening of the medial layer and intimal wall stress

Response to stress may include aortic dilation, aneurysm formation, penetrating ulcer development, intramural hemorrhage, aortic dissection, and aortic rupture

Question 4

Describe aortic dissection

Answer 4

Occurs after a violation of the intima allows bloods to enter the media and dissect between the intimal and adventitial layers

False lumen

If blood dissects through the adventitia, nearly always rapidly fatal

Question 5

Stanford A

Answer 5

Any involvement of the Ascending aorta

Question 6

Stanford B

Answer 6

Only the descending aorta

Question 7

Classic presentation for dissection:

Answer 7

Abrupt, severe pain in the chest that radiates to an area between the scapulae and may be accompanied by a feeling of impending doom

Worst pain ever

Sharp, tearing, ripping

Question 8

Is ABD pain more common in Stanford A or B?

Answer 8

B

Makes sense

Question 9

If the dissection is in or near a carotid artery, how will the patient present?

Answer 9

Stroke-y

Poor prognosis

Question 10

As a dissection works its way distal from the heart, how will sxs present?

Answer 10

Back, flank, or abd pain

Question 11

What about a proximal dissection near the aortic root?

Answer 11

Prompt tamponade

Rapidly fatal

Question 12

Common PE findings in aortic dissection?

Answer 12

HTN

If HOTN, worse prognosis

Question 13

Diagnosis aortic dissection?

Answer 13

Can be challenging due to large differential

Presenting may change as you are evaluating - distracting

Question 14

Factors associated with misdiagnosis of aortic dissection?

Answer 14

Walk-in mode of admission

Normal mediastinal width on CXR

Absent extremity pulse amplitude differences

Nonspecific sxs

Question 15

Differential for aortic dissection includes

Answer 15

MI
ACS 
Pericardial dz
Stroke
MSK dz
SCI
Intra-abdominal d/o’s
Pulm d/o’s

Question 16

Does normal CXR r/o aortic dissection

Answer 16

Hell no

Question 17

MC finding on plain films in aortic dissection? (CXR)

Answer 17

Widened mediastinum or abnormal aortic contour

Question 18

Imaging modality of choice for diagnosis of aortic dissection?

Answer 18

CT

CT can reliably identify:

• a false lumen
• anatomy of the dissection
• location of the dissection flap
• extension of the flap into the great vessels
• signs of aortic rupture
• signs of end-organ damage

Do it with and without contrast

Question 19

In experienced hands, what test can be AS SPECIFIC AS a CT?

Answer 19

Transesophageal echocardiagram

Question 20

What is the “triple rule-out”

Answer 20

Coronary CTA

CAD, PE, aortic dissection

Requires specialized contrast infusion protocol to image the three vascular beds of interest and an increased radiation dosage

Doesn’t improve diagnostic yield

Question 21

Txt for aortic dissection - pharm:

Answer 21

Short-acting BB’s (i.e. propranolol, labetolol, esmolol)

SBP 120-130 is a good starting point, try to get down to 100 if possible

Can add vasodilators like nitroprusside

Question 22

Txt for aortic dissection - surg

Answer 22

Surgery is mandatory

Type A - almost always emergenct

Type B - possible able to manage medically and get urgent surgical consult

Question 23

No pt with an acute aortic syndrome should be sent home without:

Answer 23

A consult with a cardiovascular or vascular surgeon

Question 24

Aortic dissection in preggos?

Answer 24

Rare, usually in 3rd trimester and post-partum

If type A, get that baby out (cesarean)

Question 25

A blue whale’s aorta is so large:

Answer 25

A human could climb inside it and cause an embolism