Aortic dissection

Definition
Classifications
Pathogenesis
Clinical manifestations
History
PE
 Definition

Aortic dissection is a
potentially catastrophic
condition that is due to
spread of a subintimal
hematoma within the wall
of the aorta.
Aortic dissection is the major cause of
morbidity and mortality in patients with
Marfan syndrome and similarly may
affect patients with Ehlers-Danlos
syndrome.

The incidence is also increased in

patients with inflammatory aortitis (i.e.,
Takayasu's arteritis, giant cell arteritis),
congenital aortic valve anomalies (e.g.,
bicuspid valve), coarctation of the
aorta, and a history of aortic trauma.

In addition, the risk of dissection is

increased in otherwise normal women
during the third trimester of pregnancy.
 Classification of aortic dissections
(STANFORD CLASSIFICATION)

Type A dissections (top

panels) involve the ascending
aorta independent of site of tear
and distal extension;

Type B dissections (bottom

panels) involve transverse
and/or descending aorta
without involvement of the
ascending aorta.
 Classification of aortic dissections
(DeBAKEY CLASSIFICATION)

Type I dissection involves

ascending to descending aorta
(top left)

Type II dissection is limited to

ascending or transverse aorta,
without descending aorta (top
center + top right)

Type III dissection involves

descending aorta only (bottom
left).
Hypertension is the major risk
factor for aortic dissection.
Aortas in hypertensive patients show
medial hypertrophy of the vasa
vasorum associated with ECM
degenerative changes and variable loss of
medial SMCs, suggesting that pressure-
related mechanical injury and/or ischemic
injury (due to diminished flow through the
vasa vasorum) is somehow contributory.
 A considerably smaller number of dissections
is related to inherited or acquired connective
tissue disorders causing abnormal vascular
ECM (e.g., Marfan syndrome, Ehlers-Danlos
syndrome, vitamin C deficiency, copper
metabolic defects).

Among these, Marfan syndrome is probably the

most common; it is an autosomal dominant disease
of fibrillin, an ECM scaffolding protein required for
normal elastic tissue synthesis.
Patients have skeletal abnormalities (elongated
axial bones) and ocular findings (lens subluxation)
in addition to the cardiovascular manifestations.
P
CAUSES:
a
t motor vehicle accidents or medical
procedures in which catheters or
intraaortic balloon pumps damage
hypertension and/or conditions
associated with deterioration of the
elastic or muscular components of
Pregnancy <40 yrs of
age
the intima of the aorta the media within the aorta's wall
h
o
g hematoma

e tear in the intima of the aorta rupture of the vasa vasorum within the aortic media

n
e spread of a subintimal hematoma within the wall of the aorta

s
i dissections that begin in the ascending aorta and extend to the descending
aorta tend to cause pain in the front of the chest that extends into the back,
s between the shoulder blades
Clinical manifestations

The peak incidence of aortic dissection

is in the sixth and seventh decades.

Men are more affected than women by

a ratio of 2:1.

Harrison's Internal Medicine > Chapter

242. Diseases of the Aorta >
 CHEST PAIN IN DISSECTING AORTA
ONSET Abrupt onset of unrelenting pain

PRECIPITATING Factor/s Hypertension

RELIEVING Factor/s Anti-hypertensive drugs

QUANTITY and QUALITY Very severe and tearing; ripping;
stabbing, knifelike
RADIATION Anterior chest, often radiating to back
and interscapular region, and moving
downward as the dissection progresses

ASSOCIATED SIGNS AND Diaphoresis; Other symptoms include

SYMPTOMS syncope, dyspnea, and weakness.

TIMING Sudden
PE findings
hypertension or hypotension

loss of pulses

aortic regurgitation

pulmonary edema

neurologic findings due to carotid artery

obstruction (hemiplegia, hemianesthesia) or
spinal cord ischemia (paraplegia)
 Acute aortic regurgitation is an important and
common (>50%) complication of proximal
dissection.

Signs of aortic regurgitation

bounding pulses
wide pulse pressure
diastolic murmur often radiating along the right sternal
border
evidence of congestive heart failure
Furthermore, clinical manifestations may result from the
compression of adjacent structures

superior cervical ganglia

superior vena cava
bronchus
esophagus