ESSENTIALS OF DIAGNOSIS
Sudden searing chest pain with radiation to the back, abdomen, or neck in a hypertensive patient.
Widened mediastinum on chest radiograph.
Pulse discrepancy in the extremities.
Acute aortic regurgitation may develop.
Aortic dissection occurs when a spontaneous intimal tear develops and blood dissects into the media of the aorta. The tear can result from repetitive torque applied to the ascending and proximal descending aorta during the cardiac cycle; hypertension is an important component of this disease process. Dissections are classified by the entry point and distal extent. Type A dissection involves the arch proximal to the left subclavian artery, and type B dissection occurs in the proximal descending thoracic aorta typically just beyond the left subclavian artery (eFigure 14–10, eFigure 14–11). Dissections may occur in the absence of hypertension but abnormalities of smooth muscle, elastic tissue, or collagen are more common in these patients. Pregnancy, bicuspid aortic valve, and coarctation also are associated with increased risk of dissection.
CT with contrast of chest demonstrating aneurysmal degeneration of type B dissection. White arrow, true lumen; blue arrow, false lumen with continued flow.
DeBakey and Stanford classifications of aortic dissection. DeBakey types I and II represent Stanford type A, whereas DeBakey type III is the same as a Stanford type B. (Reproduced, with permission, from Doherty GM [editor]. Current Diagnosis & Treatment: Surgery, 15th ed. McGraw Hill, 2020.)
Blood entering the intimal tear may extend the dissection into the abdominal aorta, the lower extremities, the carotid arteries, or less commonly, the subclavian arteries. Both absolute pressure levels and the pulse pressure are important in propagation of dissection. Aortic dissection is a true emergency and requires immediate control of blood pressure to limit the extent of the dissection. Type A dissection has the worse prognosis; death may occur within hours due to rupture of the dissection into the pericardial sac or dissection into the coronary arteries, resulting in MI. Rupture into the pleural cavity is also possible. The intimal/medial flap of the aortic wall created by the dissection may occlude major aortic branches, resulting in ischemia of the brain, intestines, kidney, or extremities.
Severe persistent chest pain of sudden onset radiating down the back or possibly into the anterior chest is characteristic. Radiation of the pain into the neck may also occur. The patient is usually hypertensive. Syncope, hemiplegia, or paralysis of the lower extremities may occur. Mesenteric ischemia or kidney injury may develop. Peripheral pulses may be diminished or unequal. A diastolic murmur may develop due to dissection in the ascending aorta close ...