From the Guidelines
Aortic aneurysm and dissection are medical emergencies that require prompt recognition and intervention, with clinical findings including sudden onset of severe, tearing pain, and potential complications such as malperfusion syndrome, aortic rupture, and end-organ ischemia. The presentation of aortic aneurysm and dissection can vary, but typically includes severe, tearing pain in the chest, back, or abdomen, depending on the location of the aneurysm or dissection 1. Aortic dissection often manifests as sudden, severe chest or back pain described as tearing or ripping in nature, often radiating to the neck, jaw, shoulders, or abdomen. Physical examination may reveal pulse deficits, blood pressure differences between arms, aortic regurgitation murmur, or neurological deficits from compromised blood flow.
Key Clinical Findings
- Sudden onset of severe, tearing pain
- Pulse deficits or blood pressure differences between arms
- Aortic regurgitation murmur
- Neurological deficits from compromised blood flow
- Signs of end-organ ischemia, including stroke, paraplegia, mesenteric ischemia, or acute kidney injury
Risk Factors
- Hypertension
- Family history
- Underlying collagen vascular disorders
- Advanced age
- Male gender
- Smoking
- Atherosclerosis
- Connective tissue disorders like Marfan syndrome
Management
Immediate management includes blood pressure control with beta-blockers and vasodilators if needed, pain management, and urgent imaging with CT angiography, MRI, or transesophageal echocardiography. Surgical intervention is often necessary for dissections involving the ascending aorta (Stanford type A), while medical management may be appropriate for descending aorta dissections (Stanford type B) without complications 1. The goal of management is to prevent further complications, such as aortic rupture, and to improve outcomes in terms of morbidity, mortality, and quality of life.
Imaging Studies
Imaging studies, such as CT angiography, MRI, or transesophageal echocardiography, play a crucial role in the evaluation of suspected thoracic aortic aneurysm and dissection, and should be directed toward confirming the presence of the condition, classifying the location and extent of the disease, and identifying potential complications 1.
From the Research
Clinical Findings of Aortic Aneurysm and Dissection
- The clinical manifestations of aortic dissection are usually sudden and catastrophic, with acutely severe tearing chest or back pain 2.
- Diagnostic imaging, particularly CT scans, is essential to rapidly confirm and accurately diagnose the type, magnitude, and complications of aortic dissections 2.
- The most critical findings affecting initial intervention and prognosis are obtained at CT, including:
- Involvement of the ascending aorta
- Primary intimal tear location
- Rupture
- Malperfusion
- Size and patency of the false lumen
- Complexity and extent of the dissection
- Maximum caliber of the aorta
- Progression or postintervention complications 2
Types of Aortic Dissection
- Stanford type A dissections involve the ascending aorta and have the most rapid lethal complications, requiring surgical intervention to affect morbidity and mortality 2.
- Stanford type B dissections do not involve the ascending aorta and have a lesser rate of complications in the acute phase 2.
Management of Aortic Dissection
- Beta-blockers are commonly used as first-line therapy to decrease aortic wall stress in patients with chronic type B aortic dissections 3, 4.
- However, there is limited evidence to support the use of beta-blockers as first-line therapy, and further research is needed to assess their effectiveness 3.
- Endovascular repair is a viable option for complicated type B dissections and may reduce long-term mortality outcomes 5.
- Medical management, including the use of beta-blockers, is often the optimal intervention for uncomplicated type B dissections, but the ideal intervention is still debated 5.