Aortic Dissection

Dr.med. dr. Yanto Sandy Tjang, SpBTKV, MBA, MPH,

MSc, DSc, PhD, FICS

Center for Cardiothoracic & Vascular

Surgery
Premier Hospital Jatinegara, Jakarta
25 June 2015

Definition
Aortic dissection is
an aortic wall
disease
Intimal layer
separates from the
medial layer and
this separation
continues in general
to the distal of the
Aorta
The most
catastrophic disease
of the aorta

Mortality
Acute aortic dissection
Lindsay, Hurst (1967): 33% within 24 hrs
50% within 48 hrs
80% within 7 days
95% within 1 month
for Type B: 25% at 1 month
Acute/Chronic/A/B
Anagnostopoulos (1972): 70% at 1 week
90% at 3 months

History
First known case was King George II on
October, 25, 1760
First successful repair by Dr. Michael
DeBakey in 1955.
". . . spontaneous tear of the arterial coats
is associated with atrocious pain, with
symptoms, indeed, in the case of the aorta
of angina pectoris and many instances
have been mistaken for it"
William Osler, 1910.

Epidemiology
Incidence 3/100,000 per year
Men more likely to have aortic
dissections compared to women (2.5-3)
78% have chronic hypertension
Peak for proximal dissection 50-55,
distal 60-70
At least 20% die before arriving at the
hospital

Pathogenesis
Primary intimal tear theory
Proxymal dissections 95-100%
Distal dissections 90-95%

Occurence of intramural hematoma theory

Vasovasorum rupture
Rupture of penetrating atherosclerotic ulcers

Aortic blood enter the media

Secondary rupture of the intima

Organ Malperfusion

Dynamic
obstruction
Extension of dissection into side
branches

Static
obstruction
Intimal
flap bowing into the true

Risk Factors

Classification (1)
Clinical classification
Acute: 0-14 days
Subacute: 14 days- 2 months
Chronic:
After 2 months

Topografical classification
De Bakey
Stanford
Svensson

Classification (2)

DeBakey I
Stanford
III (B)
B
Percentag
e
Type

II

A
B

60%

10-15%

DeBakey
I

DeBakey II

III (A)
25-30%

DeBakey III

Stanford A

Stanford B

Proximal

Distal

Classification of aortic dissection

Golledge et al. Lancet.

2008

Aortic Rupture
External Hemorrhage
Pericardium Tamponade (most
common)
Thorax
Hemothorax ( Left > Right)
Hemomediastinum
Abdomen
Hemoperitonium
Hemoretroperitonium
Internal Hemorrhage
GI tract
GI bleeding
Trachea
Hemoptysis

Clinical Findings

13

Pain

Acute Type A Dissection

Acute Type B Dissection

Diagnosis

Chest X-ray

CT

MRI/MRA

*Choose based on

rapid availability and

quality of performance

TTE/TEE

Aortograp
hy

Summary of Specialized
Imaging Techniques
Angiogra
phy

CT

MRI

TEE

Sensitivity

Poor

Average

Excellent

Excellent

Specificity

Good

Good

Excellent

Good

Site of
tear

Good

Poor

Excellent

Good

Aortic
Regurgitat
ion

Excellent

Useless

Excellent

Excellent

Pericardial
effusion

Useless

Poor

Excellent

Good

Coronarie
s

Excellent

Useless**

Good

Average

Aortic Dissection Mimickers

Myocardial ischemia due to an acute coronary
syndrome with or without ST segment elevation
Pericarditis
Pulmonary embolus
Aortic regurgitation without dissection
Aortic aneurysm without dissection
Musculoskeletal pain
Mediastinal tumors
Pleuritis
Cholecystitis
Atherosclerotic or cholesterol embolism
Peptic ulcer disease or perforating ulcer
Acute pancreatitis

Treatment

Medical treatment
Surgical treatment
Endovascular treatment
Hybrid treatment

Medical Treatment
Systolic BP < 100 mmHg (Labetalol,
nitroprusside)
Pain free (morphine)
Adequate renal perfusion (urine output
> 30 ml/hr)
No evidence of cerebral hypoperfusion
Minimized shear stress (-blocked to <
55/min)

Surgical Treatment
Acute
Type A Emergent surgical treatment
Type B Endovascular or medical
treatment
(surgery for
rupture, persistent symptoms,
rapidly expanding false lumen,
major organ malperfusion)

Chronic
Type A Elective surgical treatment
Type B Surgery for aneurysmatic
ischemia

aorta, organ

Endovascular Treatment
Success rate of 76100% with 25% 30day mortality
Palliative or those
unsuitable for
surgery
13% of aortic
dissections receive
stents

Hybrid Treatment

One Step
Reduction
of Interval
Concept

Mortality
Reduction of Operative
Risk

CPB
suppo
rt

Pawan et al, Ther Adv Cardiovasc Dis, 2008