Complex Aortic Dissection Treatment from Renowned Doctors

What Is Aortic Dissection?

Aortic dissection occurs when a tear forms in the inner layer of the aorta, the main artery that carries blood away from the heart to the rest of the body. As the tear extends along the wall of the aorta, blood surges through the torn tissue, causing the inner and middle layers of the aorta to dissect, or separate. This can lead to decreased blood flow to various organs or a ruptured aorta, a life-threatening emergency.

Aortic dissections can be divided into two main types:

• Type A: The most common type of aortic dissection, Type A occurs in the ascending aorta, which is the first part of the aorta (the part that leaves the heart). The tear may extend to the upper part of the aorta and down toward the abdomen. Type A is more likely to be acute than chronic. This type is more likely than Type B dissections to cause the aorta to rupture, leading to life-threatening bleeding.
• Type B: Type B aortic dissection starts in the descending aorta, which extends from the arch at the top of the ascending aorta (the part that leads upward from the heart) to the bottom section of the aorta (the abdominal aorta). Most type B aortic dissections are chronic and, as such, do not usually cause life-threatening side effects.

Symptoms of Aortic Dissection

The symptoms of aortic dissection can be similar to the symptoms of heart attack or other heart problems. Signs and symptoms include:

• Sudden, severe pain in the chest or upper back, often described as a ripping or tearing sensation, that spreads down the back or to the neck
• Abrupt, intense stomach pain
• Shortness of breath
• Loss of consciousness
• Symptoms similar to those of a stroke, including difficulty speaking, sudden vision problems and weakness or loss of movement on one side of your body
• Weak pulse in one arm or thigh compared with the other
• Difficulty walking
• Leg pain

Understanding Aortic Dissection Risk Factors

The cause of aortic dissection is unclear. In addition to advanced age and family history, the following risk factors are associated with this condition:

• Genetic connective tissue disorders, such as Marfan’s syndrome
• Hardening of the arteries
• High blood pressure
• Inflammation of the aorta (aortitis) or arteries (arteritis)
• Smoking
• Trauma

People with certain birth defects of the heart and blood vessels, such as narrowing or coarctation of the aorta and defects of the aortic valve, are also at risk for aortic dissection.

Diagnosis of Aortic Dissection

Aortic dissection must be diagnosed as quickly as possible in case emergency surgery is required. Your healthcare team needs to determine if you have aortic dissection or a different issue, such as heart attack and stroke, which can cause similar symptoms. Imaging tests that may be ordered to aid in diagnosis include:

• Chest X-ray
• Computed tomography (CT) scan
• Transthoracic echocardiogram
• Transesophageal echocardiogram (TEE)
• Magnetic resonance imaging (MRI)

How Are Aortic Dissections Treated?

Type A aortic dissection is a life-threatening condition and needs to be treated immediately, usually with open surgery. Type B dissection may be managed with surgery and/or medication.

Surgery

The two types of surgery used to fix aortic dissections are:

• Standard open-heart surgery: This surgery requires a 7- to 10-inch surgical incision be made over the middle of the sternum, or breastbone, to allow access to the heart. In some cases, a less invasive option involving a slightly smaller sternal incision is possible. In both cases, repair involves replacing the damaged portion of the aorta with a graft (a tube the same size as the aorta made from a durable artificial material) which is sutured, or sewn, into place.
  • For more severe dissections of the aortic arch (the top, arch-shaped segment of the aorta that joins the ascending aorta with the descending aorta), a surgeon may recommend an aortic arch replacement, which is an open surgical procedure in which the entire aortic arch is surgically removed and replaced with a synthetic graft. As part of the procedure, the arch blood vessels (brachiocephalic, left carotid, and left subclavian arteries), which supply the brain and other organs of the upper body, are reconnected to the synthetic graft with a separate synthetic tube with three branches (trifurcation graft).
• Endovascular aortic repair: Also called endovascular stent graft placement, this minimally invasive surgery is done without any major surgical incisions. The surgeon makes small incisions in the groin to access the femoral artery. Under x-ray guidance, a catheter is then threaded through the incision to the aorta, where it deploys a stent graft (a synthetic fabric tube supported by metal wire stents) at the site of the dissection. After the stent graft is released and opened up, it serves to reline and reinforce the weakened area of the aorta.

Medication

For aortic dissection, medications may be given to reduce heart rate and lower blood pressure in order to prevent the dissection from worsening. For example, people with a Type A aortic dissection may be blood pressure-controlling medication, often beta blockers, before their surgery. The same medications used to treat type A aortic dissection may be used with or without surgery to treat Type B aortic dissections.