Aortic dissection

Aortic dissection is a catastrophic illness that is estimated to occur at a rate of >2,000 new cases per year. It is two times more common in males, and occurs most commonly between the ages of 50 and 70 years. Early mortality can be as high as 1% per hour if left untreated. Aortic dissection results when blood separates the layers of the aortic media, usually through a tear in the intima. The tear most commonly occurs in the ascending aorta but can occur in the descending aorta or aortic arch. Hypertension is the single most important risk factor for thoracic aortic dissection. Aortic dissections are classified as either ascending or descending, depending on the location of the tear relative to the ligamentum arteriosum. The rationale for the classification of aortic dissections into ascending and descending is based on the management. Aortic dissections involving the ascending aorta require surgical management, whereas those limited to the descending aorta are managed medically. Chest pain is the most common presenting symptom and classically is described as tearing, knifelike, and ripping, with abrupt onset. Patients may also present with syncope, stroke, paraplegia or paraparesis, congestive heart failure, myocardial infarction, upper airway obstruction, dysphagia, gastrointestinal bleeding, superior vena cava syndrome, pleural effusion, new aortic regurgitation murmur and cardiac arrest. There is an unexplained relationship between pregnancy and aortic dissection. The diagnosis is made by maintaining a high index of suspicion. Once suspected, aggressive medical management of the blood pressure and pulse as well as obtaining confirmatory exams (computed tomography, magnetic resonance imaging, or transesophageal echocardiogram) and early cardiothoracic consultation can be life saving.