Aortic Dissection

What is aortic dissection?

Aortic dissection is a tear or partial tear in the lining of the largest blood vessel in the body, the aorta. This tear allows blood (and the pressure of the blood flow) to penetrate the arterial wall. Over time, this continuous flow can cause the aorta to rupture--a condition that most people do not survive.

There are two types of aortic dissections, although sometimes both conditions occur:

• Type A: A dissection to the ascending aorta is classified as a Type A dissection. These dissections can be treated medically (usually only briefly) or with interventional catheterization or open surgical techniques.
• Type B: A dissection of the descending aorta is classified as a Type B dissection. These dissections are most often treated medically with routine monitoring and prescribed medications. There is a surgical option, but it carries substantially increased risk of paralysis.

What are the warning signs and symptoms of aortic dissection?

Aortic dissections are commonly found in people with high blood pressure, arteriosclerotic vascular disease, in individuals with a family history of aortic (or thoracic) dissection and more rarely associated with congenital cardiovascular disorders (Marfan's syndrome, Ehlers-Danlos syndrome, and congenital valvular disorders).

"Stabbing" pain in the back is a common symptom of an aortic dissection. In some cases, people present with pain in the chest. This pain may be confused with angina (commonly referred to as "chest pain" and a warning sign of a possible heart attack). The main difference between pain resulting from dissection of the aorta, and angina due to lack of blood supply to the heart muscle, is its sudden and intense onset. The pain is characterized as a "ripping" or "tearing" sensation. This sudden pain can be felt in the back, chest, neck, or jaw.

These are important differences to understand. Why? Because a common recommendation to those with angina or "chest pain" (that may result in a heart attack) is to chew an aspirin to thin the blood. This is NOT the case if you are experiencing an aortic dissection. Thinning the blood for a person with aortic dissection may cause more blood to leak out of the aorta. This internal bleeding can lead to death.

In some cases, people do not experience any pain. Instead, you may experience any of the following symptoms:

• Distorted mental capacity (due to lack of blood supply to the brain)
• Numbness or tingling sensation in the arms or legs (due to lack of blood supply to the spinal cord)

If you or someone you know is experiencing any of the above symptoms, call 9-1-1 immediately to get to a hospital. The survival rate increases dramatically the sooner a person is treated for an aortic dissection.

How is an aortic dissection detected?

The key to diagnosing an aortic dissection is to confirm that it is in fact a dissection and not a heart attack, and which type it is (as the treatment options vary significantly).

The gold standard for diagnosing aortic dissection is a computed topography (CT) scan. Other imaging studies may be required to identify the type and location of the dissection. These include:

• Echocardiogram
• Magnetic resonance imaging (MRI)
• Peripheral angiography

What are the treatment options for an aortic dissection?

Three treatment options exist for an aortic dissection: 1) medical management, 2) interventional catheterization, and 3) cardiovascular surgery. Depending upon the location and severity of the dissection, your physician will decide which option is best for you.

A small percent of cases (5 - 10%) are Type B dissections (dissections of the descending aorta). This condition can be treated with surgical repair, but it carries significant risk. Typically, your doctor will monitor the condition periodically and prescribe medications to control the dissection.

The techniques used to treat dissections are as follows:

• Medical Therapy: Blood pressure and cholesterol lowering drugs, and treatment to reverse arteriosclerosis
• Endovascular Intervention: This minimally invasive procedure requires small incisions in the groin. Small wire-like, catheter devices called endoluminal stent grafts are threaded to the location of the dissection. These devices have a woven synthetic graft tip, which is deployed at the site of dissection and left in place. This provides a channel for blood to flow freely, repairing arterial leakage, and preventing pressure from rupturing the aorta. This procedure is much less invasive than the traditional open surgery, usually with a hospital stay of about 2-3 days and a recuperation period of a couple of weeks. Please note: This procedure can only be performed on specific patients based on clinical criteria, and no long-term data exists regarding its effectiveness compared to open surgery.
• Open Surgical Repair: The traditional treatment technique involves opening the chest and surgically removing the dissected aorta. A synthetic graft is sewn in its place for blood to flow freely to the rest of the arterial system. This procedure often requires a hospital stay of a week or more, and recuperation can take 6-8 weeks.