Aortic Dissection

Question 1

What is an aortic dissection?

Answer 1

A tear in the intimate of the wall of the aorta

Question 2

What is the most important risk are associated with an aortic dissection?

Answer 2

Hypertension is the most important risk factor, trauma, biscupid aortic valve

Question 3

What are the syndromes associated with an aortic dissection?

Answer 3

Collagens syndromes such as Marfan’s and Ehlers-Danlos Syndrome

Turner’s and Noonan’s syndrome

Question 4

What infection is associated with an aortic dissection?

Answer 4

Syphillis

Question 5

3 main features of aortic dissection

Answer 5

‘Sharp’ or ‘tearing’ pain - chest pain with type A and B back pain

A pulse deficit - weak or absent carotid/brachial/femoral artery or variation in systolic BP between the arms

Aortic regurgitation

Question 6

What is the systolic variation between the arms if an aortic dissection is suspected?

Answer 6

20mmHg

Question 7

In minority of patient ST elevation are seen in which leads?

Answer 7

Inferior leads, the majority have no or non-specific ECG changes

Question 8

What is the Stanford classification of aortic dissections?

Answer 8

type A - ascending aorta, 2/3 of cases

type B - descending aorta, distal to left subclavian origin, 1/3 of cases

Question 9

Describe DeBakey Classification of an aortic dissection

Answer 9

type I - originates in ascending aorta, propagates to at least the aortic arch and possibly beyond it distally
type II - originates in and is confined to the ascending aorta
type III - originates in descending aorta, rarely extends proximally but will extend distally

Question 10

What investigation would you do if you think someone has an aortic dissection?

Answer 10

It’s important to remember that patients may present acutely and be clinically unstable. The choice of investigations will have to take account of this.

Mainly a CT angiogram - false lumen is found however a Tranoesophageal echocardiography (TOE) is more suitable for unstable patients

Question 11

If you did a X-ray in a patient with an aortic dissection what would you see?

Answer 11

Widened mediastinum

Question 12

What would may an ECG show if someone has an aortic dissection?

Answer 12

May show ischaemia in specific territories if dissection extends into coronary arteries.

Question 13

What would may an echocardiogram show if someone has an aortic dissection?

Answer 13

May demonstrate pericardial effusion and aortic valve involvement.

Question 14

What would blood tests show if someone has an aortic dissection?

Answer 14

Troponin may be raised
D-dimer may be positive

Question 15

What would blood tests show if someone has an aortic dissection?

Answer 15

Troponin may be raised
D-dimer may be positive

Question 16

How would you manage Type A and B aortic dissection?

Answer 16

Type A
surgical management, but blood pressure should be controlled to a target systolic of 100-120 mmHg whilst awaiting intervention

Type B*
conservative management
bed rest
reduce blood pressure IV labetalol to prevent progression
If there is evidence of end organ damage then endovascular/open repair may be performed.

Question 17

What are the complications of aortic dissection?

Answer 17

Death due to internal haemorrhage
Rupture
End organ damage (renal or cardiac failure)
Cardiac tamponade
Stroke
Limb ischaemia
Mesenteric ischaemia

Question 18

What are the complication of a backward tear?

Answer 18

aortic incompetence/regurgitation
MI: inferior pattern is often seen due to right coronary involvement

Question 19

What are the complication of a forward tear?

Answer 19

unequal arm pulses and BP
stroke
renal failure