How might an aortic dissection present?
Acute aortic dissections are extremely dangerous, with a significant proportion of patients dying before receiving emergency medical care. The symptoms are often vague and are sometimes similar to other conditions, such as a heart attacks, making diagnosis difficult. Clinical manifestations of aortic dissection may include the following: •Acute onset severe pain that is frequently described as "tearing". The pain may be localised to the front of the chest, at the back between the shoulder blades, the neck and/or jaw. Approximately 10% of people with acute dissections will have no pain. •Collapse •Stroke •Lower limb numbness and/or weakness •Abdominal or flank pain
What causes aortic dissection?
It is unclear what causes an aortic dissection. However, there are several risk factors associated with aortic dissection, which include: •High blood pressure •Connective tissue disorders, such as Marfan disease, Ehlers-Danlos syndrome, and Turner's syndrome •Aortitis (inflammation of the aorta) •Atherosclerosis •Bicuspid aortic valve (only 2 flaps in the aortic valve, rather than the normal 3) •Blunt chest trauma e.g. seat belt injury during a car crash •Previous heart surgery •Coarctation of the aorta (narrowing of the aorta)
How is aortic dissection diagnosed?
Since the symptoms of an acute aortic dissection are non-specific and variable, it is impossible to diagnose an acute aortic dissection without imaging studies demonstrating the presence of an intimal flap. A high index of suspicion based on history, signs and symptoms is required in order to arrange the appropriate diagnostic tests. Common tests to diagnose an acute aortic dissection include: 1.Computed tomography angiography (CTa) of the chest and abdomen which gives excellent images of the entire aorta and its side branches. 2.Transoesophageal echocardiogram alternatively utilises the proximity of the aorta to the oesophagus to obtain anatomical images of the ascending aorta, arch and proximal descending aorta. 3.Magnetic resonance angiogram (MRA) of the aorta.
What is the treatment of aortic dissection?
Aortic dissections involving the ascending aorta (so called type A aortic dissections) need urgent surgical repair. Involvement of the ascending aorta risks aortic valve regurgitation, coronary mal-perfusion and cardiac tamponade: it is estimated that 50% of patients with an acute type A aortic dissection will die within 2 days of symptom onset, thus urgent treatment is imperative. Currently, treatment of acute type A dissections involves emergency sternotomy and surgical repair of the ascending aorta with a synthetic graft; aortic valve repair and/or coronary artery bypass graft may be also be required. Endovascular techniques for keyhole repair of type A dissections are in development but not ready for wider clinical application yet. Aortic dissection that does not involve the ascending aorta (so called type B dissections) are nowadays primarily treated medically with antihypertensive and heart rate control medication. Interventions are reserved for those acute type B dissection patients that develop complications such as mesenteric, kidney or lower limb ischaemia, therapy resistant hypertension or chest pain, or aortic rupture. In these circumstances, treatment will involve placement of an aortic stent (TEVAR) to cover the primary entry tear (see figure 2). It may require associated debranching procedures if the primary entry tear is very close to the origin of an important aortic side vessel such as the left common carotid artery or subclavian artery.
How will this affect me in the future?
Approximately 50% of patients will develop post-dissection aneurysms of the thoracoabdominal aorta which may require treatment depending on the size. Other complications associated with chronic aortic dissection include claudication and mesenteric ischaemia. Thus, in the longer term all patients with: a) residual dissection following repair of an acute type A dissection, or b) type B dissection, will require regular lifelong imaging surveillance with CTa or MRA scans to monitor the aorta for chronic complications.
What does Circulation Clinic offer?
At Circulation Clinic we believe patients with acute aortic dissection are best cared for in an NHS hospital and therefore our surgeons do not provide acute aortic dissection treatment outside of their NHS roles. We are able to offer on-going care for clients with chronic aortic dissections, including the treatment of associated complications. This is done within a multidisciplinary environment to ensure the most appropriate treatment is offered.
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Figure 1: Type B aortic dissection (white arrow) with right lower leg ischaemia treated with crossover bypass (black arrow).
Figure 2: Ascending aortic arch repair with hybrid graft in combination with thoracic stenting (TEVAR) of descending aorta