Aortic Dissection
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Introduction
An aortic dissection, in which the aortic intima tears and allows blood to flow through the vessel walls, is one of the most feared causes of chest pain.
Type A: involves the ascending aorta and aortic arch.
Type B: involves aorta distal to the subclavian artery
The Case of...
a simple case introducing clincial presentation and calling for a differential diagnosis to get students thinking.
Causes and Risk Factors
Pathophysiology
Signs and Symptoms
- history
- physical exam
History
Patients often describe chest pain that is:
- sudden onset
- severe
- tearing
- radiating to back
Physical Exam
Hypertension may be present
Asymmetric blood pressure and pulses between arms
Lower limb ischemia
Investigations
- lab investigations
- imaging
Lab Investigations
Lactate
amylase and lipase to rule out pancreatitis
Imaging
CXR: widened mediastinum, left pleural effusion
TEE: aortic valve and thoracic aorta can be visualized
Contrast-enhanced CT of the aorta
Bedside ultrasound may be helpful in unstable patients
- widened mediastinum
- loss of aortic knuckle
- deviation of trachea
- pleaural cap
- # of 1st or 2nd rib or scapula
- elevation of right mainstem bronchus
- depression of left mainstem bronchus
- obliteration of aortopulmonary window
- deviation of esophagus
Differential Diagnosis
Treatments
Blood pressure can be lowered with sodium nitroprusside and beta blockers
Surgery is emergently indicated for a Type A lesion, in which the ascending aorta is involved. Type B lesions are often managed medically initially, unless complications are present. These include:
- expansion
- rupture
- compromise of branches
- refractory hypertension
Consequences and Course
Resources and References
Topic Development
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