Patient Care – Adult cardiac, endovascular, and thoracic aortic surgery

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Aortic dissection is a tear in the wall of the aorta (the largest
artery of the body). This tear causes blood to flow between the layers
of the wall of the aorta and forces the layers apart. Aortic dissection
is a medical emergency and can quickly lead to death, even with optimal
treatment. If the dissection tears the aorta completely open (through
all three layers) massive and rapid blood loss occurs. Aortic
dissections resulting in rupture have a 90% mortality rate even if
intervention is timely.

Aortic dissection is a condition in which there is bleeding into and along the wall of the aorta (the major artery from the heart). This most often occurs because of a tear or damage to the inner wall of the artery. Although aortic dissection can affect anybody, it is most often seen in men 40 to 70 years old. Symptoms usually begin suddenly and require prompt medical attention.

As with all other arteries, the aorta is made up of three layers. The
layer that is in direct contact with the flow of blood is the tunica
intima, commonly called the intima. This layer is made up of mainly
endothelial cells. Just deep to this layer is the tunica media, known as
the media. This “middle layer” is made up of smooth muscle cells and
elastic tissue. The outermost layer (furthest from the flow of blood) is
known as the tunica adventitia or the adventitia. This layer is composed
of connective tissue.

In an aortic dissection, blood penetrates the intima and enters the
media layer. The high pressure rips the tissue of the media apart,
allowing more blood to enter. This can propagate along the length of the
aorta for a variable distance, dissecting either towards or away from
the heart or both. The initial tear is usually within 100 mm of the
aortic valve.

Aortic rupture (a tear in the aorta, which is the major artery coming from the heart) can be seen on a chest X-ray. In this case, it was caused by a traumatic perforation of the thoracic aorta. This is how the X-ray appears when the chest is full of blood (right-sided hemothorax) seen here as cloudiness on the left side of the picture.

The risk in aortic dissection is that the aorta may rupture, leading to
massive blood loss resulting in death.

Symptoms: Symptoms usually begin suddenly.

chest pain – sudden, severe, sharp, stabbing, tearing, or ripping, located
below the sternum, then radiates under the shoulder blades or to the back. May radiate to shoulder, neck, arm, jaw, abdomen, or hips, and location may change — pain typically moves distally (to arms and legs) as the aortic dissection progresses in the same direction.
changes in thought ability, concentration (confusion, disorientation)
decreased movement, any location
decreased sensation, any location
intense anxiety, anguish
pallor
rapid pulse (heart rate)
profuse sweating
dry skin/mouth, thirst
nausea, vomiting
dizziness, fainting
shortness of breath (dyspnea) or difficulty breathing when lying flat (orthopnea)
excessive yawning
clammy skin
weak or absent pulse
cough
high blood pressure

Treatment: The risk of death due to aortic dissection is highest
in the first few hours after the dissection begins, and decreases
afterwards. Because of this, the therapeutic strategies differ for
treatment of an acute dissection compared to a chronic dissection. An
acute dissection is one in which the individual presents within the
first two weeks. If the individual has managed to survive this window
period, his prognosis is improved. About 66% of all dissections present
in the acute phase.

In all individuals with aortic dissections, medication should be used to
control high blood pressure, if present.

In the case of an acute dissection, once diagnosis has been confirmed,
the choice of treatment depends on the location of the dissection. For
ascending aortic dissection, surgical management is superior to medical
management. On the other hand, in the case of an uncomplicated distal
aortic dissections (including abdominal aortic dissections), medical
management is preferred over surgical treatment.

Individuals who present two weeks after the onset of the dissection are
said to have chronic aortic dissections. These individuals have been
self-selected as survivors of the acute episode, and can be treated with
medical therapy as long as they are stable.

Medical management is appropriate in individuals with an uncomplicated
distal dissection, a stable dissection isolated to the aortic arch, and
stable chronic dissections. Patient selection for medical management is
very important. Stable individuals who present with an acute distal
dissection (typically treated with medical management) still have an 8
percent 30 day mortality.

Surgical management: The objective in the surgical management of
aortic dissection is to resect (remove) the most severely damaged
segments of the aorta, and to obliterate the entry of blood into the
false lumen (both at the initial intimal tear and any secondary tears
along the vessel). While excision of the intimal tear may be performed,
it does not significantly change mortality.