The diagnosis and management of aortic dissection

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Sri G Thrumurthy, honorary research fellow,
Alan Karthikesalingam, specialist registrar in vascular surgery,
Benjamin O Patterson, clinical research fellow,
Peter J E Holt, clinical lecturer in vascular surgery and outcomes research,
Matt M Thompson, professor of vascular surgery

¹Department of Outcomes Research, St George’s Vascular Institute, London SW17 0QT, UK

Correspondence to: P J E Holt pholt{at}sgul.ac.uk

Accepted 13 December 2011

Summary points

Aortic dissection is diagnosed and managed according to its anatomical extent and chronicity
White men aged over 40 years with hypertension, or those under 40 with Marfan’s syndrome or bicuspid aortic valves, are at highest risk
Patients often present with acute onset sharp chest pain, sometimes with loss of consciousness or poor perfusion of end organs
Computed tomography aortography is the first line diagnostic investigation, followed by transoesophageal echocardiography; magnetic resonance angiography is preferred for surveillance
Manage proximal (type A) dissection surgically if possible
Uncomplicated distal (type B) dissection is best managed with intensive drug treatment; complicated type B dissection requires surgical intervention
All patients need lifelong antihypertensive therapy and surveillance imaging

Aortic dissection is caused by an intimal and medial tear in the aorta with propagation of a false lumen within the aortic media. It is part of the “acute aortic syndrome”—an umbrella term for aortic dissection, intramural haematoma, and symptomatic aortic ulcer (table⇓).1 Acute dissection is the most common aortic emergency, with an annual incidence of 3-4 per 100 000 in the United Kingdom and United States, which exceeds that of ruptured aneurysm.2 ^{w1 w2} The prognosis is grave, with 20% preadmission mortality and 30% in-hospital mortality.2

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European Society of Cardiologists’ classification of acute aortic syndrome

The best treatment depends on the anatomical and temporal classification of the disease. Aortic dissection is therefore categorised according to the site of the entry tear and the time between the onset of symptoms and diagnosis. A dissection is considered “acute” when the diagnosis is made within 14 days of onset, and thereafter it is termed “chronic.” The location of the entry tear plays a key role in treatment and outcome, and it is classified by being in the ascending aorta (Stanford type A dissection) or distal to …