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Aortic dissection is the prototype and most common form of acute aortic syndromes and a type of arterial dissection. It occurs when blood enters the medial layer of the aortic wall through a tear or penetrating ulcer in the intima and tracks longitudinally along with the media, forming a second blood-filled channel (false lumen) within the vessel wall.
The majority of aortic dissections are seen in elderly hypertensive patients. In a very small minority, an underlying connective tissue disorder may be present. Other conditions or predisposing factors may also be encountered, in which case they will be reflected in the demographics. Examples include 5:
- structural aortic abnormalities
- under-recognized, common cause of dissection in young women
- prior intervention 22
- cardiac surgery
- aortic surgery
- intra-aortic balloon pumps 7
- ciprofloxacin use (unclear if class effect for fluoroquinolone agents) 20
- fluoroquinolones seem to promote loss of extracellular matrix integrity, by several mechanisms
- in the UK caution is now advised in using these agents in high-risk patients 21
Interestingly, there is a reported seasonal pattern of disease, with great risk in winter and during morning hours 22.
The duration of aortic dissection is arbitrarily categorized into three phases 18,19:
- acute: within 14 days of first symptom onset
- subacute: between 14 days to 3 months
- chronic: more than 3 months from the initial onset of symptoms
Patients are often hypertensive (although they may be normotensive or hypotensive) and present with anterior or posterior chest pain and a tearing sensation in the chest. There may be a difference in blood pressure between the two arms depending on where the dissection occurs.
Depending on the extent of dissection and occlusion of aortic branches, end-organ ischemia may also be present (seen in up to 27% of cases) 5, including:
- abdominal organ ischemia
- limb ischemia
- ischemic or embolic stroke
- paraplegia: involvement of the artery of Adamkiewicz
If the aortic dissection involves the aortic root it may result in involvement of the coronary arteries and can present similarly to ST-elevation myocardial infarction on an ECG. However, treating these patients with antiplatelets/anticoagulation could be disastrous in aortic dissection.
Some cases of aortic dissection may result in rupture, causing collapse and often death. Signs of cardiac tamponade (Beck's triad) may also be encountered if rupture occurs into the pericardial space.
There have been efforts to construct a clinical decision rule to stratify the risk of acute aortic dissection and avoid over-investigation. The aortic dissection detection risk score (ADD-RS) combined with a negative D-dimer test has been demonstrated to be effective in reducing unnecessary exams, however, it has not been widely accepted into clinical practice and requires further validation 13,14.
The normal lumen lined by intima is called the true lumen and the blood-filled channel in the media is termed the false lumen. In most cases the vessel wall is abnormal. Causes include:
- hypertension (pathogenesis: medial degeneration)
- inherited connective tissue disorders (pathogenesis: medial degeneration)
- atherosclerosis (pathogenesis: penetrating ulcer)
- vasculitis (pathogenesis: inflammation)
- pregnancy (pathogenesis: unknown)
- iatrogenic: aortic catheterization, intra-aortic balloon pump
The false lumen typically has higher and less pulsatile pressure, thought to be due to reduced distal outflow. The true lumen is often smaller due to compression by the false lumen 22.
Imaging is essential in delineating the morphology and extent of the dissection as well as allowing for classification (which dictates management). Two classification systems are in common usage, both of which divide dissections according to the involvement of the ascending aorta:
In recent years, the Stanford classification has gained favor with cardiothoracic surgeons. Approximately 60% of dissections involve the ascending aorta (Stanford A or DeBakey I and II) 5.
Aortic dissection may sometimes be classified as communicating versus non-communicating 16,17.
A new classification system was proposed which utilizes the acronym DISSECT (duration, intimal tear, size of the dissected aorta, segmental extent of involvement, clinical complications, thrombosis of the false lumen) 18.
Pleural effusions are commonly seen which increase in size during the acute phase of dissection 22.
Chest radiography may be normal or demonstrate a number of suggestive findings, including:
- widened mediastinum: >8.0-8.8 cm at the level of the aortic knob on portable anteroposterior chest radiographs 9,10, although this upper limit of normal varies (may be significantly larger) depending on projection, FFD and x-ray cassette positioning 15
- double aortic contour
- irregular aortic contour
- inward displacement of atherosclerotic calcification (>1 cm from the aortic margin) 9,11
Depending on etiology, there may be signs of periaortic or mediastinal hematoma which include:
- obscuration of the aortic knob
- opacification of the AP window
- deviation of mediastinal structures
- esophagus or nasogastric tube to the right
- trachea to the right
- left main bronchus inferiorly (decreased angle from the horizontal)
- increased thickness of the left and/or right paratracheal stripe
- apical capping, particularly on the left
CT, especially with arterial contrast enhancement and specifically computed tomography angiography (CTA) of the aorta is the investigation of choice, able not only to diagnose and classify the dissection but also to evaluate for distal complications. It has reported sensitivity and specificity of nearly 100% 3,5.
Thoracic aortic dissection can extend distally into the abdominal aorta and iliac arteries; therefore, simultaneous CT imaging of the abdomen and pelvis is often performed to identify concomitant mesenteric or abdominal visceral malperfusion.
Non-contrast CT may demonstrate only subtle findings; however, a high-density mural hematoma is often visible. Displacement of atherosclerotic calcification into the lumen is also a frequently identified finding.
Dissections involving the aortic root should ideally be assessed with ECG-gated CTA which nearly totally eliminates pulsation artifact. Pulsation artifact can mimic dissection, which is very common and seen in up to 92% of non-gated CTA studies 8.
Contrast-enhanced CT (preferably CTA) gives excellent detail. Findings include 1-3,5:
- intimal flap
- double-lumen representing the true and false lumens
- dilatation of the aorta due to aortic insufficiency 23
- an atypical variant that may be seen is an aortic intramural hematoma
- Mercedes-Benz sign in the case of a "triple-barreled" dissection
- windsock sign
- imaging features of any of the complications of aortic dissection (see below)
An essential part of the assessment of aortic dissection is identifying the true lumen, as the placement of an endoluminal stent-graft in the false lumen can have dire consequences. Distinguishing between the two is often straightforward, but in some instances, no clear continuation of one lumen with a normal artery can be identified. In such instances, a number of features are helpful 3,23:
- often compressed by the higher pressure false lumen and the smaller of the two
- has outer wall calcifications (helpful in acute dissections)
- often contiguous with the aortic root
- the origins of the celiac trunk, SMA and right renal artery usually arise from the true lumen
- often larger lumen size due to higher false luminal pressures (but size can be influenced by phase of the cardiac cycle)
- often of lower contrast density due to delayed opacification
- at risk for rupture due to reduced elastic recoil and dilation
- typical location:
- right anterolateral aspect of the ascending aorta
- left posterolateral aspect of the descending aorta
- beak sign
- cobweb sign (as slender linear areas of low attenuation specific to the false lumen due to residual ribbons of media that have incompletely sheared away during the dissection process) 3
- maybe thrombosed and seen as mural low density only (more common in chronic dissections)
- the left renal artery usually arises from the false lumen
- surrounds the true lumen in Stanford type A
Chronic dissection flaps are often thicker and straighter than those seen in acute dissections 3.
The CTA radiology report should include at least:
- proximal and distal extent of dissection
- location of the intimal tear
- associated other forms of AAS
- aortic size (largest orthogonal measurement)
- involvement and supply (from true or false lumen) of aortic branches
- presence of thrombosis in the false lumen
- signs of organ ischemia or vessel occlusion
Transesophageal echocardiography (TOE) has very high sensitivity and specificity for assessment of acute aortic dissection, but due to limited access and its invasive nature, it has largely been replaced by CTA (or MRA in some instances) 5.
Although in general MRA has been reserved for follow-up examinations, rapid non-contrast imaging techniques (e.g. true FISP) may see MRI having a larger role to play in the acute diagnosis, particularly in patients with impaired renal function 4. It has similar sensitivity and specificity to CTA and TOE 5 but suffers from limited availability and the difficulties inherent in performing MRI on acutely unwell patients.
DSA - angiography
Conventional digital subtraction angiography has historically been the gold standard investigation. CTA has now replaced it as the first-line investigation, not only due to it being non-invasive but also on account of better delineation of the poorly opacifying false lumen, intramural hematoma and end-organ ischemia.
Angiography still is required for endoluminal repair.
Risks of angiography include general risks of angiography plus the risk of catheterizing the false lumen and causing aortic rupture.
Treatment and prognosis
- aggressive blood pressure control with beta-blockers as they reduce both blood pressure and also heart rate thereby reducing extra pressure on the aortic wall
- immediate surgical repair (for type A dissection or complicated type B dissection)
Complications of all types of aortic dissection include:
- dissection and occlusion of branch vessels
- involvement can be static or dynamic 23
- abdominal organ ischemia eg kidneys (left kidney most common), bowel, spleen
- limb ischemia
- ischemic stroke
- paraplegia: involvement of artery of Adamkiewicz
- distal thromboembolism
- aneurysmal dilatation: this is an indication for endovascular or surgical intervention 6
- aortic rupture
Specifically, Stanford type A dissection may also result in:
- coronary artery occlusion (right coronary artery more common 22)
- aortic incompetence
- rupture into the pericardial sac causing hemopericardium with resulting cardiac tamponade
Although the combination of blood pressure control and surgical intervention has significantly lowered in-hospital mortality, it remains significant, at 10-35%. Over the 10 years following diagnosis another 15-30% of patients require surgery for life-threatening complications 5.
Specifically, Stanford type B dissection the false lumen may 23:
- thrombose (partially or completely)
- remain stable
- progress in the caudocranial direction
The differential on chest x-ray is that of a dilated thoracic aorta.
On CT, a number of entities that can mimic a dissection should be considered 5:
- pseudodissection due to aortic pulsation motion artefact (typically left anterior and right posterior aspects of the ascending aorta)
- pseudodissection due to contrast streaks
- mural thrombus
- intramural hematoma: really an atypical type of aortic dissection and part of the acute aortic syndrome
- penetrating atherosclerotic ulcer which is part of the acute aortic syndrome
- adjacent atelectasis
- minimal aortic injury
Clinically, a number of causes of acute chest pain are often considered:
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