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  • • Often lethal event

    • Degeneration of aortic media is hallmark of disease

    • Pathogenesis controversial

    • 1. Medial degeneration leads to rupture of vasa vasorum

      2. Intimal tears allows blood to shear weakened media

    • Location of intimal tear: Ascending aorta, 62%; arch, 10%; isthmus, 16%; rest in distal aorta

    • Risk factors include:

    • -Hypertension

      -Atherosclerosis

      -Iatrogenic injury (catheter or open heart surgery)

      -Closed chest trauma

      -Marfan syndrome

      -Aortic coarctation

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Classification

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  • • Debakey type I

    • -Originate in ascending aorta

      -Extend beyond left subclavian (Stanford type A)

    • Debakey type II

    • -Involve ascending aorta only

      -Often chronic

      -Associated with aortic valve incompetence (Stanford type A)

    • Debakey type III

    • -Occur distal to left subclavian artery

      -Often extend into abdominal aorta (Stanford type B)

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Epidemiology

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  • • Most common cause of aortic rupture

    • 2000 cases yearly

    • Men affected more often than women

    • Usually occurs in fifth to seventh decades of life

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Symptoms and Signs

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  • • Most common

    • -Severe, tearing chest pain often signifies intimal tear and formation of false lumen

      -Ascending: Pain anterior

      -Descending: Pain posterior between scapulas

    • Hypotension with blood loss, leak into pericardium

    • Sudden death if extends into pericardium or down a coronary artery

    • If involves aortic valve or root, aortic insufficiency and acute congestive heart failure

    • Obstruction of aortic branch vessels:

    • -Stroke

      -Asymmetric extremity pulses

      -Paraplegia

      -Renal failure

      -Acute mesenteric ischemia

      -Lower extremity occlusion

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Laboratory Findings

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  • • ECG: Useful to rule out myocardial infarction (MI)

    • Cardiac enzymes: Rule out MI

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Imaging Findings

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  • Chest film

    • -50% have widened mediastinum

      -Cardiomegaly if in failure or with pericardial effusion

      -Left pleural effusion if contained rupture

    Chest CT: Diagnostic procedure of choice

    Transesophageal echocardiography (TEE)

    • -Information about myocardial function

      -Aortic valve competence

      -Diagnostic

      -Limited in evaluation of arch and descending dissections

    Magnetic resonance angiography (MRA): Useful but time-consuming

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Rule Out

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  • • MI

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  • • Physical exam

    • ECG

    • Chest x-ray

    • Chest CT scan

    • Transesophageal echocardiogram

    • MRA if stable

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  • • Aggressive blood pressure control critical; esmolol commonly used (decreases dP/dT and aortic shear force)

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Ascending

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  • • Death occurs from cardiac tamponade, acute coronary occlusion, acute atrial regurgitation

    • Replacement of ascending aorta with resection of intimal tear

    • Resuspension of aortic valve commissures restores valve competence

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Descending

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  • • Majority have benign course

    • Medical therapy treatment of choice

    • 20% require surgery for rupture or organ ischemia

    • 20% develop aneurysmal dilation of aorta requiring surgery

    • Endovascular stent procedure and fenestration are new approaches being studied

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Medications

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  • • β-Blockers (esmolol)

    • Vasodilators if still hypertensive after β-blockade

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Complications

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  • • Untreated ...

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