Overview
Definition
A tear in the intimal layer of the aorta allowing blood to enter and separate (dissect) the layers of the aortic wall, creating a false lumen.
Epidemiology
A catastrophic and highly lethal cardiovascular emergency. More common in men > 60 years.
Etiology & Risk Factors
- Chronic Hypertension (most common risk factor)
- Connective tissue disorders (Marfan syndrome, Ehlers-Danlos)
- Bicuspid aortic valve
- Cocaine use
- Trauma
Clinical Symptoms
- Sudden, severe, 'tearing' or 'ripping' chest or back pain
- Pain radiating to between the shoulder blades
- Syncope
- Asymmetrical blood pressures or pulses between arms
Clinical Approach
Diagnosis
- CT Angiography (CTA) of the chest/abdomen/pelvis (Gold Standard - shows intimal flap)
- Transesophageal Echocardiogram (TEE) if unstable
- Chest X-ray (widened mediastinum - classic but not sensitive)
Management
- Stanford Type A (Ascending aorta): SURGICAL EMERGENCY. Immediate open repair.
- Stanford Type B (Descending aorta only): Medical management if uncomplicated (strict BP/HR control with IV Esmolol/Labetalol to target HR < 60 and SBP < 120); TEVAR if complicated.
Complications
- Aortic rupture (rapid death)
- Cardiac tamponade (if dissects retrograde into pericardium)
- Acute aortic regurgitation
- Malperfusion syndromes (Stroke, Mesenteric ischemia, Renal failure)