89 MD ARH 2011, 65(2) ORIGINAL PAPER

Follow-up of Acute Aortic Dissection

ORIGINAL PAPER
Follow-up of Acute Aortic Dissection
Lulzim S. Kamberi
1
, Daut R. Gorani
1
, Ahmet M. Karabulut
2
, Arton I. Beqiri
3
, Ardian I. Mustafai
4
University Clinical Centre of Kosova, Prishtina, Kosova
1
Department of Cardiology, Istanbul Medicine Hospital, Istanbul, Turkey
2
International Medicine Hospital for Cardiovascular Disease, Prishtina, Kosova
3

University Clinical Centre of Skopje, Cardiology Clinic, Skopje, Macedonia
4
I
ntroduction. Aortic dissection is a tear in the wall of the aorta. It is a
medical emergency. If left untreated the mortality rate is extremely high.
Aortic dissection is divided into two types, A and B. Primary, because of
low suspicion the diagnosis can delay. Te natural history is poorly under-
stood. Objectives. Our objectives were to improve diagnosis of aortic dissec-
tion. To encourage use of trans esophageal echo cardiography in emergency
room. To clarify the role of prompt treatment in prognosis of aortic dissection.
Methods. Tis study was approved by the Committee of Ethics. All of the
patients signed a informed consent. Clinical evaluation was performed by
expert cardiologists, using diferent modalities. A complete medical history
and physical examination were performed. Te follow-up time of patients
was 24 months. Results. Eleven patients were included in this study. Male/
female ratio was 2.7:1. Type A was present in 7 patients, hypertension in 9.
All patients were symptomatic. Tree patients died, two in the emergency
center, one after surgery. Surgery was performed in fve patients, all with
type A dissection. Four survived patients after operation and all patients
with type B dissection survived follow-up time of 24 months. Conclusion.
Most crucial step in aortic dissection diagnosis remain clinical suspicion.
It should be confrmed rapidly since it is lifesaving. We want to emphasize
that the trans esophageal echo cardiography is very useful exam to make the
diagnosis which is the key for correct treatment and for follow-up. It must
be widely available in the emergency centre. Key words: aorta, aortic
dissection, type A dissection.
Corresponding author: Lulzim S. Kamberi, MD. Mother Theresa Street. No number, 10 000 Pristina, Kosova.
Phone: +377 44 14 56 80; e-mail: lulzimkamberi@gmail.com
1. INTRODUCTION
Aortic dissection is caused by an in-
timal tear within an abnormal, weak-
ened vessel wall. Tis leads to blood en-
tering the wall, with subsequent propa-
gation in the media both proximally and
distally, displacing the intima inward.
Te two well-known classifcation sys-
tems, De Bakey and Stanford, are based
on two parameters: the origin of the in-
timal tear and the extent of involvement
of the aorta. Te Stanford system clas-
sifes aortic dissection into two types,
A and B. Type A involves the ascending
aorta (regardless of the origin of the in-
timal tear), with or without involvement
of descending aorta. Surgical interven-
tion is required for type A dissection.
In contrast, type B afects only the de-
scending aorta and generally requires
only conservative medical treatment (1).
Te estimated incidence of aortic dis-
section is 5 to 30 cases per million peo-
ple per year (2, 3, 4, 5). Men are more
frequently afected by aortic dissection,
and a male/female ratio ranging from
2:1 to 5:1 has been reported in diferent
studies (6, 7). Te peak-age for the oc-
currence of proximal dissection is be-
tween 50 and 55 years, and that of distal
dissection is between 60 and 70 years.
Chronic systemic hypertension is the
most common factor predisposing the
aorta to dissection and has been present
in 62 to 78% of patients with aortic dis-
section (2, 3, 8).

Te natural history of
aortic dissection is poorly understood.
Earlier information on aortic dissection
was gained mostly from autopsy stud-
ies, while newer clinical or pathologic
studies came from large referral centers
and were based on selected nonconsec-
utive cases (2). According to the results
of the study,by Meszaros et al, (9) based
on the epidemiology and clinicopathol-
ogy of aortic dissection, 21% of patients
with aortic dissections die before hos-
pital admission. Te mortality rate for
patients with untreated proximal aor-
tic dissections has been reported to in-
crease by 1 to 3% per hour after presen-
tation and is approximately 25% during
the frst 24 h after the initial presenta-
tion, 70% during the frst week, and 80%
at 2 weeks (7, 10). Less than 10% of un-
treated patients with proximal aortic
dissections live for 1 year, and almost
all patients die within 10 years (9). Most
of these deaths occur within the frst
90 MD ARH 2011, 65(2) ORIGINAL PAPER
Follow-up of Acute Aortic Dissection
3 months. Earlier data (collected from
six studies) reported by Anagnostopou-
los et al. (11) on 963 untreated patients
with aortic dissections, 90% died within
3 months of presentation with the con-
dition. Death is usually caused by acute
aortic regurgitation, major branch ves-
sel obstruction, or aortic rupture. Te
risk of the fatal aortic rupture in pa-
tients with untreated proximal aortic
dissections is around 90%, and 75% of
these ruptures take place in the peri-
cardium, the left pleural cavity, and the
mediastinum (12). Te 10-year actuarial
survival rate of patients with an aortic
dissection who leave the hospital alive
ranges from 30% to 60% (13,14,15,16).
Tus, prompt diagnosis is critical When
aortic dissection is suspected clinically,
urgent cross-sectional imaging is re-
quired. CT (computed tomography),
MRI (magnetic resonance imaging),
and TEE (trans esophageal echo cardi-
ography) have been shown to be equally
reliable for confrming or excluding the
diagnosis of dissection (17).
In summary, surgical therapy is
the treatment of choice for type A aor-
tic dissection For type B aortic dissec-
tion, patients with no complications are
at present treated conservatively, with
the main objective to control blood
pressure (18).
2. METHODS
Tis study was approved of by the
Committee of Ethics of the Internal
Clinic. All of the patients signed a Term
of Free Informed Consent. We studied
11 patients. Clinical Evaluation was
performed by expert cardiologists us-
ing clinical criteria, Chest radiography,
TTE (transthoracic echo cardiography),
TEE and CT of the chest. A complete
medical history and physical examina-
tion were performed, and heart rate,
systolic blood pressure, diastolic blood
pressure, and ECG were recorded. All
of the procedures were performed by
an expert echocardiographist using
PHILIPS iE33 equipment attached to
a multi frequency 2.5 to 3.5 MHz for
TTE and 7.0 MHz for TEE multi plane
transducer. Te echo cardiograms were
performed with the patients in left de-
cubitus and the upper left limb slightly
fexed beneath the head. For TEE exam-
ination patients were advised previously
to maintain a 4-hour fast, and were
submitted to oropharyngeal anesthe-
sia with lidocaine spray. Te transducer
was introduced through the mouth and
into the esophagus and gastric cavity for
visualization of the cardiac and aorta
structures. Te images were obtained
according to the recommendations of
the American Society of Echo cardiog-
raphy. Systolic and diastolic left ven-
tricular (LV) dimensions, and systolic
and diastolic function indexes were
obtained. Aorta was presented almost
entirely (ascending, arch and descend-
ing part). Te results were analyzed by
a standard method of descriptive statis-
tics using Excel Ofce 2007.
3. RESULTS
Eleven (11) patients were included
in this study. Average age of all pa-
tients was 58 years (584). Eight (8) of
them were men of the average age of
56.5 years (56.5 3.12); three (3) were
women of average age of 62 years (62
3.46). Male/female ratio was 2.7 : 1.
Type A dissection was present in seven
cases (7) or 63.64%, while four (4) were
type B (Table 1). Te average age of pa-
tients with type A dissection was 57.57
4.39 years and for type B, the average
age was 58.75 3.59, Table 2. All pa-
tients were symptomatic. Hypertension
was present in nine (9) patients or 82%
of patients (Table 1). Five (5) patients
with hypertension had type A dissec-
tion. Diabetes was present in 3 cases, 2
of them of dissection type A. Te dis-
section was fatal for three (3) patients
or 27.8% of cases. All three were type
A (Table 3). Two died in the emergency
center. Te diagnosis was delayed. One
of the patients died after the surgery
(the operation was done after a few days,
because of the inability of this kind op-
eration at our center). Surgery was per-
formed in fve patients, all with type
A dissection. One patient with type B
dissection had ischemic heart disease.
Patients were followed for 24 months.
Four (4) patients with type A dissec-
tion who survived surgery, survived
also the period of 24 months. All had
regular control and their blood pres-
sure was strictly controlled. Also, all
the patients with type B dissection sur-
vived for 24 months. Tey were under
strict regular medical control. TEE was
performed regularly (every 6 months).
Two patients developed an aneurysm
in the area of dissection, but below the
criteria for surgery. Two patients in re-
peated TEE examinations had no signs
of dissection, considered as the healed
dissection.
4. DISCUSSION
Te study included 11 patients who
were followed for at least 24 months.
nr.=11 nr.
Male 8
Female 3
Symptomatic 11
Hypertension 9
Diabetes mellitus 3
Coronary artery disease 1
Operation 5
Death 3
Death after the operation 1
Death because of delayed
diagnosis
2
Type A dissection 7
Type B dissection 4
Table 1. Baseline data of the patients. pt-patients
Patients
(nr.)
Mean age
year
St. dev.
pt. (11) 58.00 4.0
Male (8) 56.5 3.12
Female (3) 62 3.46
Type A dissection
(7)
57.57 4.39
Type B dissection
(4)
58.75 3.59
Table 2. Mean age of the patients, according to
sex and type of dissection
nr. pt.=11
Type
A
Type
B
Total
pt.=11 7 4 11
Male 6 2 8
Female
Male/female
1 2
3
2.7 /1
Symptomatic 7 4 11
Hypertension 5 4 9
Diabetes mellitus 2 1 3
CAD* 0 1 1
Operated 5 0 5
Not operated 2 4 6
Death 3 0 3
Death after the
operation
1 0 1
Death because of
delayed diagnosis
2 0 2
Table 3. Main data of the patients-according to
type of dissection. CAD-Coronary artery disease,
pt-patients
91 MD ARH 2011, 65(2) ORIGINAL PAPER
Follow-up of Acute Aortic Dissection
Males were more afected than females.
Male/female ratio was 2.7: 1. Te aver-
age age of patients with dissection type
A was 57.57 years which does not dif-
fer signifcantly from the reported av-
erage age of 50-55 years. For type B
dissection the average age was 58.75
years which also does not difer signif-
icantly from the reported age of 60-70
years. Hypertension was present in 82%
of cases, which is similar to values re-
ported in other stu dies (2, 3, 8). Seven
patients had type A dissection. Tree
patients died; two of them in the Emer-
gency Center, after a signifcant de-
lay in diagnosis. Te frst was initially
suspected to sufer from hypertension
and acute coronary syndrome and the
other from abdominal pain of an un-
known nature, possibly pancreatitis.
Diagnosis was established after a delay
of several hours. According to Hagan et
al. and Kodolitsch et al., up to 30% of
patients later found to have aortic dis-
section are initially suspected to have
other conditions, such as acute coro-
nary syndromes, non dissecting aneu-
rysms, pericarditis, pulmonary embo-
lism, aortic stenosis, or even cholecysti-
tis (2, 10).

A routine chest x-ray is abnor-
mal in 60% to 90% of cases of suspected
aortic dissection. However, acute dis-
section (especially type A) can present
with a normal chest flm, and this may
distract physicians from pursuing fur-
ther imaging (2, 19). ECG analysis may
also be misleading because it may be
normal in dissection or very abnormal
when ascending dissection causes cor-
onary compromise. In our study, with
the exception of patients with ischemic
heart disease, no others have had spe-
cifc ECG changes to confrm diagno-
sis. In our study the diagnosis was al-
ways made just after suspicions for the
problem so a high index of suspicion is
more important than the type of test
used (20). Each institution, depend-
ing on their capabilities, should estab-
lish pathways for diagnosis, early treat-
ment, and eventual transfer to defnitive
care as soon as possible. Te diagnosis
of dissection is complex, primarily be-
cause of atypical symptoms and signs
and because of low suspicion of it. On
the contrary, in the case of suspected
dissection the diagnosis can be done
easily and very quickly, either with CT
or TEE. Tis shows that
TEE and CT should be routinely used
in emergency centers for such cases.
TEE can be performed safely even at the
bedside. Possible complications of TEE
are very rare. In our study we followed
patients for at least 24 months during
which we did not have any complica-
tions in repeated TEE (every 6 months).
5. CONCLUSION
Te aortic dissection is a relatively
rare but very serious process. Since it
may occur anywhere in the aorta, the
clinical spectrum of presentation is
broad and unpredictable. We want to
emphasize that the most crucial step
in aortic dissection diagnosis remain
clinical suspicion which should be con-
sidered for patients with hypertension
and other cardiovascular risk factors
who present with chest pain. Further-
more, TEE and CT are very high-per-
formance exams to make the diagno-
sis which is the key for successful treat-
ment and for correct follow-up. So they
must be widely available in the emer-
gency centre. Te diagnosis should be
confrmed rapidly and accurately since
it is lifesaving.
REFERENCES
1. Pansini S, Gagliardotto PV, Pompei E, Pa-
risi F, Bardi G, Castenetto E, et al. Early
and late risk factors in surgical treat-
ment of acute type A aortic dissection.
Annual Toracic Surgery. 1998 Septem-
ber; 66(3): 779-84.
2. Hagan PG, Nienaber CA, Isselbacher
EM, Bruckman D, Karavite DJ, Russ-
man PL, et al. Te International Regis-
try of Acute Aortic Dissection (IRAD):
new insights into an old disease. JAMA.
2000; 283, 897-903.
3. Khan IA, Nair CK. Clinical, diagnostic,
and management perspectives of aor-
tic dissection. Chest. 2002; 122: 311-328
4. Bickerstaf LK, Pairolero PC, Hollier LH,
Melton LJ, Van Peenen HJ, Cherry KJ, et
al. Toracic aortic aneurysms: a popu-
lation-based study. Surgery. 1982; 92,
1103-1108.
5. Eisenberg MJ,Rice SA,Paraschos A,Ca-
puto GR,Schiller NB. Te clinical spec-
trum of patients with aneurysms of the
ascending aorta. American Heart Jour-
nal. 1993; 125: 1380-1385.
6. Auer J, Berent R, Eber B. Aortic dissec-
tion: incidence, natural history and im-
pact of surgery. Journal of Clinical Basic
Cardiology. 2000; 3: 151-154.
7. Hirst AE. Jr., Johns VJ. Jr., Kime SW. Jr.
Dissecting aneurysms of the aorta: a re-
view of 505 cases. Medicine. 1958; 37:
217-279.
8. Hennessy TG, Smi t h D, McCann
HA,McCarthy C, Sugrue DD. Toracic
aortic dissection or aneurysm: clinical
presentation, diagnostic imaging and
initial management in a tertiary referral
center. Ireland Journal of Medical Sci-
ence. 1996; 165, 259-262.
9. Mszros I, Mrocz J, Szlvi J, Schmidt
J, Tornci L, Nagy L. et al. Epidemiology
and clinicopathology of aortic dissection.
Chest. 2000; 117, 1271-1278.
10. Pitt MP., Bonser RS. Te natural history
of thoracic aortic aneurysm disease: an
overview. Journal of Cardiovascular Sur-
gery. 1997; 12 (supplement): 270-278.
11. Anagnostopoulos CE, Prabhar MJS, Kit-
tle CF. Aortic dissection and dissecting
aneurysms. American Journal of Cardi-
ology. 1972; 30, 263-273.
12. Veyssier-Belot C, Cohen A, Rougemont
D, Levy C, Amarenco P, Bousser MG.
Cerebral infarction due to painless tho-
racic aorta and common carotid artery
dissection. Stroke. 1993; 24, 2111-2113.
13. Pansini S, Gagliardotto PV, Pompei E, Pa-
risi F, Bardi G, Castenetto E, et al. Early
and late risk factors in surgical treat-
ment of acute type A aortic dissection.
Annual Toracic Surgery. 1998 Septem-
ber; 66(3): 779-84.
14. Umaa JP, Lai D.T, Mitchell RS, Moore
KA, Rodriguez F, Robbins RC, et al. Is
medical therapy still the optimal treat-
ment strategy for patients with acute type
B aortic dissections? Journal of Toracic
Cardiovascular Surgery. 2002 November;
124(5): 896-910.
15. Bernard Y, Zimmermann H, Chocron S,
Litzler JF, Kastler B, et al. False lumen
patency as a predictor of late outcome
in aortic dissection. American Journal of
Cardiology. 2001 Jun 15; 87 (12): 1378-82.
16. Lai D.T, Robbins RC, Mitchell RS., Moore
KA, Oyer PE, Shumway NE, et al. Does
profound hypothermic circulatory arrest
improve survival in patients with acute
type a aortic dissection? Circulation.
2002; 24; 106 (12 Supplement 1): 218-28.
17. Shiga T, Wajima Z, Apfel CC, Inoue T.
Ohe Y. Diagnostic accuracy of trans
esophageal echo cardiography, helical
computed tomography, and magnetic
resonance imaging for suspected tho-
racic aortic dissection: systematic re-
view and meta-analysis. Archive of In-
ternal Medicine. 2006; 166: 1350-1356.
18. Ince H, Nienaber CA. Diagnosis and
management of patients with aortic dis-
section. Heart. 2007; 93: 266-270.
19. Kodolitsch Y, Schwartz AG., Nienaber
CA. Clinical prediction of acute aortic
dissection. Archive of Internal Medicine.
2000; 160: 2977-2982.
20. Christoph A, Nienaber MD, Kim A, Eagle
MD. Aortic Dissection: New Frontiers in
Diagnosis and Management. Part I: From
Etiology to Diagnostic Strategies. Circu-
lation. 2003; 108:628.