Table 1

Malperfusion syndromes during an evolving aortic dissection

DiagramBranch arteries affectedClinical signs/symptomsMeans of restoring perfusion/further management
ACoronary

  • Hallmark signs of myocardial ischaemia

  • ST elevation on ECG

  • Raised troponin

  • Resuscitative management (avoid antiplatelet agents, thrombolysis and anticoagulation)

  • Aortic root replacement

  • Aorto-coronary bypass with suitable conduit (eg, saphenous vein, internal mammary artery)

BCarotid

  • Symptoms of stroke

  • Focal neurological deficit

  • Aortic arch replacement

  • Carotid artery stenting

  • Aorto-carotid bypass

CSubclavian

  • Radio-radial delay, brachial blood pressure discrepancy

  • Carotid-subclavian bypass

  • Arch replacement

DSpinal

  • Signs of ischaemic spinal cord injury

  • Paraparesis, paraplegia

  • Spinal protection strategies (eg, cerebrospinal fluid drainage)

  • Descending aortic replacement with left heart bypass +/-segmental artery reimplantation

EMesenteric

  • Abdominal pain/tenderness, deranged metabolic profile, hyperlactataemia

  • Resuscitative management,

  • Aortic stent with fenestration,

  • Arterial bypass

  • Patient likely to require bowel resection if blood supply not restored

FRenal

  • Acute renal failure

  • Reduced urine output

  • Metabolic acidosis, hyperkalaemia

  • Renal artery stenting

  • Aortic stent with renal artery fenestration

GIliac and femoral

  • Acute lower limb ischaemia

  • Calf, buttock pain

  • Usually unilateral (more common in right)

  • Iliac/femoral artery stenting

  • Lower limb arterial bypass surgery