Nursing management of patients with aortic dissection

2. INTRODUCTION
 Aortic dissection is a serious condition in which there
is a tear in the wall of aorta.
 Aortic dissection is the surging of blood through a tear
in the aortic intima with separation of the intima and
media and creation of a false lumen (channel).
 During an aortic dissection the inner layer of aorta
tears, letting blood in where it usually doesn’t go.
 This causes the inner and middle layers to separate,
or dissect.
 If the blood bursts through the outer wall of aorta, it’s
life-threatening and needs immediate repair.

3.  It occurs when blood enters the medial layer
of the aortic wall through a tear or penetrating
ulcer in the intima and tracks along the media,
forming a second blood-filled channel within
the wall.

5. DEFINITION
Aortic dissection is the tearing
in the innermost lining of the
arterial wall of aorta that
allows blood to enter between
the intima and media , thus
creating a false lumen.

6. INCIDENCE
 Aortic dissection affect men 2 to 5 times
more often than women.
 Occurs most frequently in the sixth and
seventh decades of the life.

7. CLASSIFICATION
DeBakey classification system.
Stanford system.
Based on symptom onset.

8. DEBAKEY CLASSIFICATION
SYSTEM
 type I: involves ascending and
descending aorta (= Stanford A)
 type II: involves ascending aorta only
(= Stanford A)
 type III: involves descending aorta
only, commencing after the origin of
the left subclavian artery (= Stanford
B)

9. STANFORD SYSTEM
 TYPE A: A affects ascending aorta and arch
 accounts for ~60% of aortic dissections & start before left
subclavian artery.
 surgical management
 may result in:
 coronary artery occlusion
 aortic incompetence
 rupture into pericardial sac with resulting cardiac tamponade
 TYPE B: B affects descending aorta.
 accounts for ~40% of aortic dissections
 dissection commences distal to the left subclavian artery
 medical management with blood pressure control

13. BASED ON SYMPTOM ONSET
Acute(First 14 days).
Subacute( 14-90 days).
Chronic( greater than 90
days)

14.  Approximately two third of dissections involve
the ascending aorta and are acute in onset.
 Chronic dissections are almost type B.

15. ETIOLOGY
There are numerous factors that will increase the
risk of aortic dissection. Some factors are :
 Chronic Hypertension.
 Atherosclerosis, or hardening of the aortic walls
 Hypercholesterolemia
 Rare: traumatic injury to chest area( Blunt or
Iatrogenic).
 Sex. Men have about double the incidence of
aortic dissection.
 Connective tissue disorders( Marfan’s or
Ehlers-Danlos) Syndrome.

16.  Age. The incidence of aortic dissection peaks in the
60s and 70s.
 Cocaine use.
 Aortic diseases( aortitis, coarctation ).
 A history of aortic aneurysm
 Family history
 Congenital heart disease( Bicuspid aortic valve)
 History of heart surgery
 Pregnancy
 High-intensity weightlifting

17.  Chronic Hypertension usually degenerate
elastic fibers in the arterial wall.
 Half of the all acute aortic dissections in
patients younger than 40 years of age occur in
patients with Marfan’s syndrome.

18. PATHOPHSIOLOGY

19. PATHOPHYSIOLOGY

20. CLINICAL MENIFESTATIONS
 Severe chest pain often described as a tearing,
ripping or shearing sensation, that radiates to the
neck or down the back. It occurs in 80% of
patients with acute Type A aortic dissection.
 Pain in the back, abdomen or legs . It occurs
more in clients with Type B aortic dissection.
 Shortness of breath
 Sudden difficulty speaking, loss of vision,
weakness, or paralysis of one side of body, such
as having a stroke.
 Sweating

21.  Neurological deficits : Altered level of
consciousness, weakened or absent carotid and
temporal pulses and dizziness or syncope( If
aortic arch involved)
 Type A aortic disscetion: There is angina, M.I. A
new high pitched murmur sound. In severe
cases left sided heart failure, cardiogenic shock,
death.
 Subclavian artery is involved radial, ulnar,
brachial pulse may be different the left and right
arms.

22. COMPLICATIONS
 Cardiac tamponade.
 Aortic rupture leads to hemorrhage into the
mediastinal, pleural or abdominal cavities.
 Spinal cord ischemia.
 Renal failure due to renal ischemia.
 Abdominal ischemia.
 Death due to internal bleeding.
 Aortic regurgitation & Stroke.

23. DIAGNOSTIC EVALUATION
 Health history.
 Physical examination.
 ECG may rule out cardiac ischemia.
 Chest X ray may show widening of mediastinum
and pleural effusion.
 CT scan & MRI provide information on severity
of aortic dissection.
 Magnetic resonance angiography.
 Transesophageal echocardiography : when
patient is very unstable or when CT & MRI are
contraindicated.

24. MANAGEMENT
. An aortic dissection is a medical emergency
requiring immediate treatment. Therapy may
include surgery or medications, depending on the
area of the aorta involved.
The initial goals of therapy without complications are
heart rate and BP control
General measures includes:
1) Bed rest.
2) ICU hospitalization.
3) Blood transfusion (if needed)

25. PHARAMACOLOGICAL
MANAGEMENT
 I.V. Beta blocker(esmolol) to lower Blood
pressure & heart rate.
 Calcium channel blockers(diltiazem) can
be used to lower heart rate when beta
blockers are contraindicated.
 Morphine reduces pain through
decreasing sympathetic nervous system
stimulation.

26. CONSERVATIVE THERAPY
 The patient with acute or chronic Type
B aortic dissection without
complication can be treated through:
1) Pain relief.
2) BP and Heart rate control.
3) CVD risk factor modification
4) Close surveillance imaging with CT or
MRI.

27. SURGICAL MANAGEMENT

29. ENDOVASCULAR
DISSECTION REPAIR(EVAR)
 It is indicated for acute & chronic
type B aortic dissection . Two
procedures are recommended under
these endovascular treatment:
A. Thoracic endovascular aortic
repair(TEVAR).
B. Endovascular Fenestration.

30. THORACIC ENDOVASCULAR
AORTIC REPAIR(TEVAR)
 TEVAR or stent grafting is a minimally
invasive treatment for an aortic dissection.
 A cloth-covered stent graft is used to seal
the tear in the aorta.
 One or more uncovered stents may be
added to support and expand the true
lumen in order to improve blood flow to
your abdominal organs, pelvis and legs.

31.  Complications are Major or minor stroke (up
to 5–7% of cases); insufficient blood supply to
the spinal cord, which can lead to leg paralysis
(up to 3%), and extension of the dissection (up
to 3%).

34. ENDOVASCULAR
FENESTRATION
 Endovascular fenestration is done to improve
blood flow to a specific branch artery or to help
equalize pressure between the true and false
lumens.

36. OPEN SURGICAL REPAIR
 Indications of open surgery are:
I. Acute type A aortic dissection.
II. Chronic dissection with connective
tissue disorder.
III. A descending thoracic aortic diameter
greater than 5.5 cm.

38.  Once surgeon has found the tear, he or
she will use man-made (synthetic) grafts
to replace the damaged parts of the aorta.
If r aortic valve is damaged, surgeon may
also put in a replacement valve.
 When surgeon has made all of the repairs,
he or she will remove the heart bypass
machine and close incision.

39.  Surgeon will make a cut (incision) in
chest or belly (abdomen). The exact spot
will depend on where dissection is
located.
 A heart bypass machine will take over
pumping blood around heart and lungs.

41. NURSING DIAGNOSIS
 Ineffective tissue perfusion related to
compromised arterial blood
flow secondary to blood extravasation via
aortic dissection.

42. NURSING INTERVENTION
 Continuously monitor arterial BP during acute
phase to evaluate the patient’s response to
therapy.
 Monitor hourly urine output because a drop in
output may indicate renal artery dissection or a
decrease in arterial blood flow.
 Continuously monitor ECG for dysrythmia
formation, ST segment or T-wave changes,
suggesting coronary sequelae or a decrease in
arterial blood flow.

43.  Assess neurologic status to evaluate the
course of dissection. Confusion or changes in
sensation and motor strength may indicate
compromised cerebral blood flow (CBF).
 Auscultate for changes in heart sound
and signs and symptoms of heart failure,
which may indicate that the dissection involves
the aortic valve.
 Compare BP and pulses in both arms and legs
to determine differences.

44. PROGNOSIS
 About 20% of patients with aortic dissection die before
reaching the hospital. Without treatment, mortality
rate is 1 to 3%/h during the first 24 h, 30% at 1 wk,
80% at 2 wk, and 90% at 1 yr.
 Hospital mortality rate for treated patients is about
30% for proximal dissection and 10% for distal. For
treated patients who survive the acute episode,
survival rate is about 60% at 5 yr and 40% at 10 yr.
About one third of late deaths are due to
complications of the dissection; the rest are due to
other disorders.

45. PREVENTION
 Control blood pressure.
 Don't smoke.
 Maintain an ideal weight.
 Wear a seat belt.
 Work with your doctor: If Patient has
family history of aortic dissection or
bicuspid aortic valve.