The document provides an extensive overview of aortic dissection and related syndromes, outlining aspects such as anatomy, classification, clinical manifestations, investigation methods, and management strategies. It categorizes aortic diseases, details risk factors, explores diagnostic techniques, and discusses treatment approaches including pain management and blood pressure control. Key points include the critical nature of aortic dissection as a cardiac surgical emergency and the implications of aortic aneurysms and other related conditions.

1. AORTIC DISSECTION &
AORTIC RELATED
SYNDROMES
Shauqi Norizan
Supervisor : Dr Asmalia Khalid

2. OUTLINES
• Introduction
• Prevalence
• Anatomy
• Pathophysiology
• Classification
• Risk factors
• Clinical Manifestation
• Approach
• Investigation
• Management

3. INTRODUCTION
• Aortic disease includes conditions such as:
Chronic aortic aneurysms
Acute aortic syndromes (aortic dissection, intramural hematoma,
penetrating atherosclerotic ulcer, periaotic hematoma, intimal tear
without tear, aortic trauma)
Congenital aortic abnormalities (Marfan’s syndrome and
coarctation of the aorta)
• The incidence of aortic diseases is expected to rise with the
increasing age of the population

4. ANATOMY
Divided into 4 section:
• Ascending aorta
 left and right coronary artery
• Aortic arch
 brachiocephalic trunk/left common carotid artery/ left subclavian artery
• Descending aorta
 bronchial arteries/mediasternal artery/oesophageal artery/pericardial
artery/superior phrenic artery/ intercostal and subcostal artery
• Abdominal aorta
 inferior phrenic artery/ superior mesenteric artery/inferior mesenteric
arteries/ celiac trunk/ suprarenal /renal artery/gonadal artery/lumbar
artery/common celiac artery

5. THE THORACIC AORTA
• Aortic root - from the aortic
annulus, including the sinuses of
Valsalva, up to the level just above
the sinotubular junction
• Ascending aorta - from the sinotubular
junction to the innominate artery,
average diameter of 3 cm
• The arch - from the innominate
artery to the left subclavian
artery
• The descending thoracic aorta -
average diameter of 2.5 cm, begins
after the origin of the left subclavian
artery.

6. THE ABDOMINAL AORTA
• Begins when the descending thoracic aorta passes through
the diaphragm.
• The abdominal aorta (average diameter 2.0 cm) is further
branches into Suprarenal and Infrarenal portion

7. HISTOLOGY
It is composed of three layers:
• The intima - is the innermost layer and includes the
single-layered endothelium.
• The media - is the thickest layer of the aortic wall and is
composed of sheets of elastic tissue, smooth muscle cells,
and collagen, which provide the aorta with its tensile
strength and distensibility.
• The adventitia - is the outermost layer; it is composed
of loose connective tissue and contains the vasa
vasorum, which constitutes the blood supply to the
aortic wall

9. AORTIC DISSECTION
• Separation of the layers of the aortic wall due to an intimal
tear
• Involves splitting of the aortic wall within the media,
which results in the formation of an aortic false lumen that
courses along with a true lumen.
• The hallmark of aortic dissection is an intimal tear, which
allows access of pulsatile high pressured blood into the
aortic media, separating it from the outer layers. Often, the
so-called intimal flap is usually an intimal-medial flap.

10. • Often occurs along the
right lateral wall of the
ascending aorta where
the hydraulic shear
stress is high.
• Another common site is the
descending thoracic aorta
just below the ligamentum
arteriosum.

11. • The initiating event is either a
primary intimal tear with
secondary dissection into the
media or a medial hemorrhage
that dissects into and disrupts
the intima.
• The pulsatile aortic flow then
dissects along the elastic
lamellar plates of the aorta and
creates a false lumen.
• The dissection usually
propagates distally down the
descending aorta and into its
major branches, but it may
propagate proximally

12. CLASSIFICATION
• 2 commonly used classifications
are De Bakey and Stanford
• Others like Svensson, and the newly
considered classification TEM (Type of
dissection, location of the tear of the
primary Entry and Malperfusion)

13. Type Extent of Aortic Involvement
DeBakey
I Originates in ascending aorta, propagates to involve descending aorta
II Confined to ascending aorta
IIIa Confined to descending thoracic aorta
IIIb Involves descending aorta, extending to abdominal aorta
Stanford
A Involves ascending aorta
B Restricted to descending aorta

14. RISK FACTORS
2 categories:
• Condition that contribute to medial degeneration
• Condition that increase aortic wall stress

16. CLINICAL MANIFESTATION
SYMPTOM
• Acute onset of chest or back
pain (80 to 90 %)
• Severe, sharp, or ‘tearing’ and is
located in the anterior chest
pain for type A
• and in the posterior chest or
back pain for type B.
SIGN
• asymmetry limb pulse
• shock, syncope, acute congestive
heart failure, MI, stroke,
paraplegia, extremity ischemia,
mesenteric ischemia
• aortic regurgitation
• pericardial effusion
• acute coronary syndrome

17. • Patients typically present with acute onset of pain
• Pain is often most severe at its onset and described as a tearing,
ripping, or stabbing sensation. Often, the pain is migratory, a crucial
component of the history, reflecting propagation of the dissection.
– Involvement of the ascending aorta results in anterior chest or neck pain,
– Involvement of the descending thoracic aorta results in intrascapular
or subscapular pain
– Involvement of thoraco abdominal aortia results in lower back and left
flank pain.
• Hypertension on presentation is common, more so in distal
dissection, although hypotension can be seen if complications have
developed, particularly in proximal dissections.
• The dissection may compromise flow to the great vessels and lead
to pulse deficits.

18. • If the dissection involves the aortic root, commissural involvement of
the aortic valve can lead to aortic regurgitation. A diastolic murmur
is evident in these cases.
• Dissections can involve the ostia of the coronary arteries,
resulting in acute myocardial ischemia and infarction.
• The dissection can extend proximally into the pericardial space,
resulting in pericardial effusion and tamponade.
• Rupture into the pericardial space represents a common mode of
death in patients with aortic dissection.
• Malperfusion syndromes with acute lower extremity, renal, or
mesenteric ischemia can be seen in descending aortic dissections.
• Focal neurologic deficits can occur with involvement of the great
vessels. Compromise of spinal artery perfusion may result in
paraparesis.

20. DDX
• acute coronary syndrome
• pulmonary embolus
• spontaneous pneumothorax
• aortic regurgitation without dissection
• oesophageal rupture
• pericarditis
• pleuritis

21. INVESTIGATION
• Biochemicals
• D-dimer, fbc, busec, electrolytes, LDH, GXM, cardiac biomarkers, coagulation profile
• Electrocradiogram
• can be normal but often shows nonspecific ST-T wave changes. Involvement of the
coronary artery ostia can result in ST-segment elevation, representing an acute
myocardial injury pattern
• Chest radiography
• may be normal in cases of dissection
• Mediastinal widening, present in about 60% of cases
• Rupture into the pleural or pericardial space manifests as pleural effusions or an
enlarged cardiac silhouette

25. • A 'normal' chest x-ray does not rule out the possibility of
an aortic dissection.
• Chest x-ray sensitivity for the diagnosis of aortic disease is
64%.
• Chest x-ray specificity for the diagnosis of aortic disease is
86%.
• Chest x-ray has particularly low accuracy in the diagnosis of
ascending aortic dissection.
• More definitive diagnostic modalities include
Echocardiography & Ultrasonography, Computed
tomography (CT) and Magnetic resonance angiography
(MRA).

26. Echocardiography & Ultrasonography
• Is a useful bedside tool for the rapid diagnosis of aortic dissection in
the ED, bedside, fast, no need contrast, no radiation
• TEE is more superior than TTE but need a skillful operator.
• The aortic root dilatation seen on the PSLA view & the presence of an
intimal flap seen on either transthoracic or transabdominal views of
the aorta are both highly sensitive for aortic dissection
• TTE can measure aortic root via parasternal long-axis view or apical
view. Aortic valves can also be assessed.
• Suprasternal view can visualise aortic arch with three major vessel
• Subcostal view can depict abdominal aorta.
• Dx of AD require identification of flap – major limitation due to
frequent artefact

28. Visualization of an intimal flap
by ultrasound may carry a
sensitivity of 67–80% and
specificity of 99–100% for
dissection

30. CT & MRI
• CT and MRI are both highly accurate in identifying the intimal flap
and the extent of the dissection and involvement of major arteries;
each has a sensitivity and specificity >90%
• Contrast enhancement can visualised hemopericardium, aortic
rupture and branch vessel involvement.

35. MANAGEMENT
1. Pain management
• IV opioids for analgesia (eg, fentanyl, morphine)
2. Blood pressure control
• Anti – impulsive/anti hypertensive therapy by controlling the blood pressure
to minimize the likelihood of rupture or progression
• Control heart rate <60 BPM
3. Immediate transfer for CTVS or endovascular intervention

36. Choice of anti hypertensive agent: B-blocker
• Esmolol :250 to 500 mcg/kg IV loading dose, then infuse at 25 to 50
mcg/kg/minute; titrate to maximum dose of 300 mcg/kg/minute)
• Labetolol (20 mg IV initially, followed by either 20 to 80 mg IV boluses
every 10 minutes to a maximal dose of 300 mg, or an infusion of 0.5 to 2
mg/minute IV)
If Beta blockers are not tolerated, alternatives are verapamil, diltiazem, or
nicardipine.
• IF SBP >120 mmHg, initiate nitroprusside infusion (0.25 to 0.5
mcg/kg/minute titrated to a maximum of 10 mcg/kg/minute) or
nicardipine infusion (2.5 to 5 mg/hour titrated to a maximum of 15
mg/hour)
• Vasodilator therapy (eg, nitroprusside, nicardipine) should not be used
without first controlling heart rate with beta blockade.

37. CONSULTATION
• Aortic dissection involving the ascending aorta is a cardiac surgical
emergency
• Aortic dissection involving only the descending thoracic aorta or
abdominal aorta and with evidence of malperfusion is treated with
urgent aortic stent-grafting or surgery.
• Aortic dissection involving only the descending thoracic aorta or
abdominal aorta without evidence for ischemia is admitted to the
ICU/medical for medical management of hemodynamics and serial
aortic imaging.
• If appropriate surgical services◊ are not available, initiate emergent
transfer to nearest available cardiovascular center.

38. AORTIC ANEURYSM
• Aortic aneurysm, refers to enlargement of
the aorta beyond its normal diameter.
• A segment of the aorta is called aneurysmal if
its maximal diameter is greater than 1.5 times
that of the adjacent proximal normal
segment.
• Fusiform Aneurysm - if it symmetrically
involves the entire circumference of the aorta.
• Saccular aneurysm involves a localized
protrusion of one of an area of the vessel
wall.

39. CAUSES
• Congenital:- primary connective tissue disorder (Marfan’s, syndrome,
Ehlers- Danlos Syndrome) and other diseases (focal medial agenesis,
tuberious scierosis, Turner’s Syndrome, Menkes’syndrome)
• Mechanical (hemodynamic):-Poststenotic and Arteriovenous fistula
and amputation related.
• Traumatic (pseudoaneurysms): Penetrating arterial injuries blunt arterial
injuries pseudoaneurysms

40. • Inflammatory (noninfectionus ): Associated with arteritist
(Takayasu’s diseases giant cell arteritis ,systemic lupus erythematosus
,Behcet’s syndrome, Kawasaki’s disease) and periarterial
inflammation (i.e percreatitis).
• Infectious (mycotic ): Bacterial, fungal, spirochetal infections.
• Pregnancy –related degenerative: Nonspecific inflammatory variant
.
• Anastomotic (post-arteriotomy) and graft aneurysms:
Infection, arterial wall failure, suture failure, graft failure.

41. True Aneursym
• When an aneurysm involves all three layers of the arterial wall or
the attenuated wall of the heart.
• Further divided according to the shape and size into Saccular &
Fusiform aneurysms.
Fasle Aneurysm
• Or pseudoaneurysm, is not an aneusysm but a disruption of all
layers of the arterial wall resulting in bleeding that is contained by
surrounding structure

44. CLINICAL PRESENTATION
• Often asymptomatic at time of presentation. Physical findings
may also be absent.
• When signs and symptoms occur, they are often the result of
mass effect:
– The enlarging aorta can compress nearby structures, such as the SVC,
trachea, esophagus, and recurrent laryngeal nerve. This can result in
the SVC syndrome, stridor, dysphagia, and hoarseness.
– Progressive dilation of the aortic root can lead to aortic regurgitation,
which may produce symptoms of congestive heart failure.
– Enlargement of the aortic sinuses can lead to narrowing of the
coronary artery ostia, lead to myocardial ischemia/infarction.
– Blood flow can be static in large aneurysms, predisposing to atheroma
and thrombus formation and distal embolization.

45. DIAGNOSTIC
• Chest X-Ray are useful in demonstrating the mediastinal silhouette
and any abnormal widening of the thoracic aorta.
• Plain X-Ray of the abdomen may show calcification within the wall of
abdominal aorta aneurysms
• Electrocardiogram (ECG)may be performed to rule out evidence of
myocardial infarction (MI)
• Echocardiography assists in the diagnosis of aortic valve insufficiency
related to ascending aortic dilation

46. EMERGENCY DEPARTMENT CARE &
DISPOSITION
• Stabilize hemodynamics by obtaining large-bore IV access and
administering fluids judiciously to treat hypotension.
• Target a goal systolic blood pressure of 90 mm Hg, and transfuse packed
red blood cells if needed.
• Provide pain control while avoiding hypotension.
• Consult emergently with a vascular surgeon when a rupturing AAA or
aortoenteric fistula is suspected.
• When a small asymptomatic AAA (3.0 to 5.0 cm) is identified as an
incidental finding, refer the patient to see a vascular surgeon.
• Large AAAs (>5.0 cm) are at higher risk for spontaneous rupture and may
warrant close follow-up

47. AORTIC INTRAMURAL
HEMATOMA
Defined as a hematoma confined
within the medial layer of the
aorta in the absence of a
detectable intimal tear, although
microtears may be present

48. PENETRATING AORTIC ULCER
• Refers to a region of the aorta (ulcer like
projection) where the aortic intima is denuded
with the lesion progressing through a variable
amount of the aortic wall
• which there may or may not be overlying
thrombus.
• Penetrating aortic ulcers are typically
associated with atherosclerotic changes of the
adjacent aortic wall

49. Reference
• Tintinalli’s Emergency Medicine Manual 8th Edition: Chapter 42
• UPTODATE, Overview of acute aortic dissection and other acute aortic syndromes
• A review of aortic disease research in Malaysia, Gerald Tan Jack Soon, MBBS1 , Paul Khoo Li Zhi, MBBS1 , Sailesh Mohana Krishnan, MBBS1 ,
Chan Kok Meng John, FRCS CTh2 1 Newcastle University Medical School, Johor, Malaysia, 2 Cardiothoracic Department, Cardiac Vascular
Sentral Kuala Lumpur (CVSKL) Hospital, Kuala Lumpur, Malaysia
• https://www.mdedge.com/emergencymedicine/article/132738/imaging/identification-aortic-dissection-using-limited-bedside
• http://www.meddean.luc.edu/lumen/meded/radio/curriculum/surgery/dissecting_aorta.htm