Overview Snapshot A 32-year-old man with eunuchoid proportions and arachnodactyly presents to the ER complaining of sudden onset of severe substernal chest pain with pain radiating down his back. CXR shows a widened mediastinum. Introduction Characterized by an intimal tear in the wall of the aorta causing a second blood-filled lumen to form Risk factors include hypertension trauma coarctation of the aorta syphilis Ehlers-Danlos syndrome Marfan's Syndrome Turner Syndrome pregnancy copper deficiency Prognosis good to excellent if dissection is identified and treated early ranges depending on location and severity of disease Classification Stanford Classifications Type A dissection involves the ascending aorta can include Debakey Types I, II, and III Type B occurs distal to the left subclavian artery only includes Debakey Type III Debakey Classifications Type I originate in ascending aorta propagate at least to the aortic arch often beyond aortic arch distally Type II originates in and confined to the ascending aorta Type III originate in descending aorta rarely extends proximally, but can extend distally Presentation Symptoms patients classically present with the triad of acute-onset, severe, tearing chest pain radiating to the back widened mediastinum on chest radiograph asymmetric, upper extremity BP and pulses severe cases may present with syncope shock sudden death Physical exam asymmetric, upper extremity BP and pulses diastolic murmur secondary to aortic regurgitation Evaluation Retrograde arteriography is diagnostic gold standard demonstrates double lumen of aortic dissection Transesophageal echo also useful in identifying aortic dissection in unstable patients CT with IV contrast also useful in identifying aortic dissection EKG may show LVH and ischemic changes CXR shows widened superior mediastinum Differential MI, PE, angina, thoracic aortic aneurysm, esophageal rupture, pancreatits, pancreatic pseudocyst, neoplasms, orthopaedic causes of back pain, appendicitis, and gallbladder disease Treatment Nonoperative hemodynamic stabilization with control of HTN and tachycardia indications all patients in acute phase prior to surgical intervention medical management alone may be considered in Type B patients who are poor surgical candidates monitoring paying careful attention to BP and HR to prevent further dissection/rupture medications labetalol and IV nitrates to control hypertension Operative surgical intervention with graft placement indications required immediately in Type A dissections Type B dissections who are good surgical candidates Prevention and Complication Prevention medical management may delay worsening of disease adequate control of HTN and HR Complications aortic dissection can result in sudden death when not identified or treated properly