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Diseases of the aorta and trauma to the aorta and heart
Aortic dissection: medical, interventional and surgical management
  1. Miriam Silaschi1,
  2. Jonathan Byrne2,
  3. Olaf Wendler1
  1. 1Department of Cardiothoracic Surgery, King's College Hospital, London, UK
  2. 2Department of Cardiology, King's College Hospital, London, UK
  1. Correspondence to Professor Olaf Wendler, Department of Cardiothoracic Surgery, King's College Hospital London, Denmark Hill, London SE5 9RS, UK; olaf.wendler{at}nhs.net

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Learning objectives

After reading this article, the readers should be able to:

  • Recognise ‘red flags’ in clinical history and examination of a patient suggestive of aortic dissection and streamline the right diagnosis.

  • Initiate acute medical treatment and recognise the urgency for further invasive treatment.

  • Recognise objectives of surgical therapy and identify postoperative complications specific for patients with aortic dissection.

Introduction

Acute aortic dissection (AAD) is a relatively rare but much-feared clinical presentation which has a high mortality, particularly if definitive treatment is delayed. A combination of aortic wall stress and abnormalities of the medial layer of the aortic wall leads to disruption of the media and an intimal tear with subsequent penetration of blood, which splits the aortic wall layers. This creates a cavity within the medial layer, the so-called false lumen (FL), which is separated from the native true lumen (TL) by the dissection membrane.1 This process can result in disruption of the adventitia (aortic rupture) or in a second tear in the dissection membrane, which allows blood to re-enter the TL. If AAD occurs within the ascending aorta (AA), 40% of patients die immediately and mortality is 1%–2% for each hour afterwards resulting in a 48-hour mortality of approximately 50% (see figure 1).2

Figure 1

Spontaneous prognosis of acute aortic dissection (adapted from Kirklin et al).51

The most important risk factor for the development of AAD is poorly controlled hypertension. Men are more often affected and the risk increases with age. Other important pathogenic factors are positive family history and genetic history (connective tissue disease, Ehlers-Danlos syndrome, Marfan syndrome), aortic disease and aortic valve (AV) diseases, history of cardiac surgery and previous trauma.3 ,4 Although dilatation of the aorta (aortic aneurysms) increases the risk through greater wall stress, AAD can as well occur in patients with …

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