Thoracoabdominal aortic dissection (TAAD) is an infrequent clinical entity. Virchows Arch Pathol Anat 276: 187–229, Davies MJ, Treasure T, Richardson PD (1996) The pathogenesis of spontaneous arterial dissection. It may be that two to three times as many patients die of dissections as of ruptured aortic aneurysms; approximately 75% of patients with ruptured aortic aneurysm will reach an emergency department alive, whereas for aortic dissection 40% die immediately. Peter M. Schulman MD, Rondall Lane MD, in Critical Care Secrets (Fourth Edition), 2007. London: His Majesty’s Stationary Office, Eagle KA, DeSanctis RW (1989) Aortic dissection. Nonvascular lesions close to the aortic dissection may be misdiagnosed as the cause of the symptoms. Collateral circulation also determines whether ischemic symptoms result from occlusion of the ostia of the radicular branches. These patients die of pericardial tamponade, rupture, aortic valve dysfunction, or malperfusion of the coronary arteries. The 30-day mortality rate for uncomplicated type B dissection is 10%. This phenomenon may partly explain how extensive aortic dissections can cause either no symptoms or only transient ones. Download full-text PDF Read full-text. La dissection aiguë de l’aorte thoracique ascendante est une condition pathologique potentiellement catastrophique, exigeant une prise en charge tant diagnostique que thérapeutique urgente. Patients with such complications necessitating intervention have a higher mortality of at least 30%.4, Asheesh Kumar MD, Rae M. Allain MD, in Critical Care Secrets (Fifth Edition), 2013. Am J Roentgenol Radium Ther Nucl Med 122: 769–82, Urban BA, Bluemke DA, Johnson KM, Fishman EK (1999) Imaging of thoracic aortic disease. For untreated acute dissection of the ascending aorta the mortality rate is 1% to 2% per hour after onset. The estimated incidence is 5 to 30 cases per million people per year. Omid Shafe MD, in Practical Cardiology, 2018, Aortic dissection is one of the most catastrophic events with a high mortality rate. For type A dissections treated medically it is approximately 20% within the first 24 hours and 50% by 1 month after presentation. Mortality for an untreated dissection is about 25% at 6 hours and 50% by 24 hours. Acta Radiol 39: 368–76, Stein HL, Steinberg I (1968) Selective aortography, the definitive technique, for diagnosis of dissecting aneurysm of the aorta. Even with surgical intervention, the mortality rate for type A dissection may be as high as 10% after 24 hours and nearly 20% 1 month after repair. The condition most frequently occurs in men in their 60s and 70s… Copyright © 2020 Elsevier B.V. or its licensors or contributors. Although risk of rupture is unclear, management of IMH is typically the same as for aortic dissection. Am Surg 42: 395–404, Nienaber CA, von Kodolitsch Y, Petersen B, David TE, Feindel CM (1992) An aortic valve-sparing operation for patients with aortic incompetence and aneurysm of the ascending aorta. The blood supply of the spinal cord was described in some classic works a few decades ago. Chest 122:311–328, 2002. Old standards and new directions. Although type B dissection is less dangerous than type A, it is still associated with an extremely high mortality. Ann Intern Med 20: 486–511, Eagle KA, Isselbacher EM, DeSanctis RW; International Registry for Aortic Dissection (IRAD) Investigators (2002) Cocaine-related aortic dissection in perspective. New York: McGraw-Hill, p. 61–70, Hirst AE Jr, Johns VJ Jr, Kime SW Jr (1958) Dissecting aneurysm of the aorta: a review of 505 cases. The 30-day mortality rate for an uncomplicated type B dissection approaches 10%. The estimated incidence is 5–30 cases per million people per year. DeBakey first identified variations in aortic dissection based on both the origin of the initial tear as well as the extent of aortic dissection. Download full-text PDF. MD, Michael D. Dake MD, in Comprehensive Vascular and Endovascular Surgery (Second Edition), 2009, Aortic dissection is a more common problem than is ruptured abdominal aortic aneurysm. A re-appraisal. Aortic dissection is a relatively rare but highly lethal disease. Anesthetic considerations in this patient population are similar to those undergoing AAA repair and both open and endovascular surgical techniques have been used. Aortic dissection: Tear in the intimal layer, leading to formation of a false lumen in the medial layer of the aorta, potentially propagating antegrade or retrograde in the aortic wall. Even with surgery, the mortality rate for type A dissection may be as high as 10% after 24 hours and nearly 20% 1 month after repair. Atherosclerosis and systemic hypertension are thought to be the most common causes of aortic dissection initiated by intimal tears. Whereas aortic dissection has been used synonymously with dissecting aortic aneurysm, dissecting aortic hematoma is also appropriate to describe this condition. Am Heart J 132: 1301–4, Erdheim J (1930) Medianecrosis aortae idiopathica cystica. A 39 year-old, previously healthy, male presents to your emergency department with the chief complaint of chest pain. Despite improvements in surgical, anesthetic, interventional, and medical techniques, even the mortality and morbidity of treated patients remain high. N Engl J Med 317: 1060–7, Slater EE (1983) Aortic dissection: presentation and diagnosis. Saunders p. 1214–5, Kouchoukos NT, Masetti P, Rokkas CK, Murphy SF (2001) Single-stage reoperative repair of chronic type A aortic dissection by means of the arch-first technique. The in-hospital mortality rate is about 59% among medically treated patients with type A aortic dissection.16 Also, the in-hospital mortality rate is about 13% among patients with type B aortic dissections.17 The incidence of aortic dissection has been rising, partly because of the improvement in and availability of diagnostic methods. The rule of thumb has been a mortality of 1% per hour in the acute stage. Kenneth J. Cherry Jr. MD, Michael D. Dake MD, in Comprehensive Vascular and Endovascular Surgery (Second Edition), 2009. Medicine (Baltimore) 37: 217–79, Sorensen HR, Olsen H (1964) Ruptured and dissecting aneurysms of the aorta. The majority of late deaths are from rupture of the false lumen because its long-term patency sets the stage for aneurysmal dilation and rupture. Isolated dissection of the abdominal aorta is rare; most commonly, the intimal tear originates within a few centimeters of the left subclavian artery. However, collateral circulation does not account for the low incidence of clinical ischemic syndromes of the spinal cord compared with the cerebral circulation. Little is known about the frequency of anatomic variations between individuals because these studies have not been repeated recently because of the tedious work involved in dissecting and identifying the various branches. Cardiol Clin 17: 659–82, Shellock FG, Curtis JS (1991) MR imaging and biomedical implants, materials, and devices: an updated review. La dissection aiguë de l’aorte thoracique ascendante est une condition pathologique potentiellement catastrophique, exigeant une prise en charge tant diagnostique que thérapeutique urgente. This misdiagnosis has sometimes resulted in inappropriate operations on these "incidental" lesions in an attempt to alleviate symptoms. J Thorac Cardiovasc Surg 103: 617–21, Zhang H, Li M, Jin W, Wang Z (2004) Endoluminal and surgical treatment for the management of Stanford Type A aortic dissection. Damian Baalmann. Aortic dissections that involve the ascending aorta (Stanford type A) are considered surgical emergencies. Khan IA, Nair CK: Clinical, diagnostic, and management perspectives of aortic dissection. Recent work, however, suggests four distinct time periods: hyperacute (symptom onset <24 hours), acute (2–7 days), subacute (8–30 days), and chronic (>30 days), with a mortality rate that continues to increase significantly even into what is traditionally considered the chronic phase. Blood surges through the tear, causing the inner and middle layers of the aorta to separate (dissect). Classically, dissections are labeled acute when clinical symptoms have lasted for 14 days or less and chronic if symptom duration exceeds 2 weeks. It is noteworthy that thoracic aortic dissection is a common cause of TAAs (see Box 22.1).21, Enrique J. Pantin MD, Albert T. Cheung MD, in Essentials of Cardiac Anesthesia, 2008. Aortic dissection is a more common problem than is ruptured abdominal aortic aneurysm. For type A dissection treated medically, it is approximately 20% within the first 24 hours and 50% by 1 month after presentation. Not logged in Pain is the most common presenting symptom, occurring in approximately 95% of patients, and is usually described as sudden in onset.2, Acute aortic dissection is highly lethal if not recognized and treated aggressively. Acute type B dissections are responsible for approximately one-third of all aortic dissections. Not affiliated The gap between the intima and media in aortic dissection causes symptoms through different mechanisms. NATURAL HISTORY. Rupture is frequently preceded by dissection. Chest 122: 311–28, Shennan T (1934) Dissecting aneurysms. Early thoracic endovascular aortic repair (TEVAR) may be beneficial in a select group of uncomplicated TAAD. The clinical presentation of isolated abdominal aortic dissection may vary depending on end-organ compromise; abdominal pain, visceral ischemia, acute renal failure, and limb ischemia have all been reported. Aspects diagnostiques, thérapeutiques et évolutifs de la dissection aortique à Dakar. Haytham Elgharably, ... Eric E. Roselli, in Cardiology Secrets (Fifth Edition), 2018. However, patients with type B dissection who have complications such as limb ischemia, renal failure, or visceral ischemia have a 2-day mortality upwards of 20% and may prompt the need for surgical intervention. Am J Roentgenol Radium Ther Nucl Med 102: 333–48, Cigarroa JE, Isselbacher EM, DeSanctis RW, Eagle KA (1993) Diagnostic imaging in the evaluation of suspected aortic dissection. In this article, the author has thrown light on epidemiology, etiopathogenesis, clinical presentations, diagnostic, and treatment approaches for TAAD. Unable to display preview. Special report Medical Research Council series No. Iam delighted to see that my predictions were accurate in regard to this effective Heart 75: 344–5, Wheat MW Jr (1987) Acute dissection of the aorta. The Stanford classification system simplifies the schema by entry site only, with Stanford type A dissection originating in the ascending aorta and Stanford type B dissection originating in the descending aorta. TEVAR is a new frontier for management of acute complicated TAAD and has almost supplanted open surgical repair (OSR) in view of high incidence of paraplegia, prolonged hospital stay, and pulmonary complications associated with OSR. Aortic rupture: Full-wall thickness tear, leading to cardiac tamponade among other complications. Survenant le plus souvent dans un contexte d'hypertension artérielle, elle associe - dans les formes typiques - une douleur Cardiovasc Clin 17: 241–62, Seldinger SI (1953) Catheter replacement of the needle in percutaneous arteriography; a new technique. Two population-based studies indicated incidences of 2.9 and 3.5 acute aortic dissections per 100,000 person years.2,3 It is seen more often in men, with a ratio of 5:1. Aortic dissection occurs in 5 to 30 out of every 1 million people.3 It can affect men and women of all ages but is most commonly seen in men between 60 and 80 years of age.4 The most important risk factors for aortic dissection are uncontrolled high blood pressure and atherosclerosis (hard- Penetrating atherosclerotic ulcer (PAU): Infiltration of the media by an atherosclerotic plaque, most commonly in localized areas in the descending aorta. During the early hours after type A aortic dissection, the mortality risk increases about 1% per hour.15 As time passes, the mortality rate increase slows down but is still high. According to the International Registry of Aortic Dissection (IRAD), a worldwide registry of 21 centers with consecutively enrolled patients, the in-hospital mortality for all dissections is 27%. Sabiston & Spencer Surgery of the chest. Population-based studies suggest that the incidence of acute dissection ranges from 2 to 3.5 cases per 100,000 person-years, which correlates with 6000 to 10,000 cases annually in the United States. In this chapter, discussion of aortic dissection will be limited to abdominal aortic dissections. Consequently, the arbitrary distinction of acute dissection is less than 14 days, and chronic dissections are those surviving more than 2 weeks. Circulation 105: 1529–30, Rashid J, Eisenberg MJ, Topol EJ (1996) Cocaine-induced aortic dissection. Selke F, Swanson S, del Nido P, eds. Ischemia of the spinal cord causes predominantly lower motor neuron signs because the gray matter needs more oxygen than the white matter does. This is a preview of subscription content, DeSanctis RW, Doroghazi RM, Austen WG, Buckley MJ (1987) Aortic dissection. Semin Thorac Cardiovasc Surg 5: 11–6, Roberts CS, Roberts WC (1991) Dissection of the aorta associated with congenital malformation of the aortic valve. Cite as. Circulation 35: 880–8, Pate JW, Richardson RL, Eastridge CE (1976) Acute aortic dissections. ... Doucoure I, Sarr M, et al. Incidence and prospects of surgery. Animal experiments have shown that the overall oxygen needs of the spinal cord are about two fifths that of cerebral tissue. Patients with type A treated medically have a mortality of 58%, whereas mortality for surgical treatment of type A dissections is 26%. Aortic dissection is a relatively rare but a highly lethal disease. Thoracic aneurysms and diameter of the aorta, especially in patients with genetic disorders, are two of the most important risk factors of aortic dissection; however, only 16% of patients with thoracic aortic dissection have known aneurysms. Mortality and morbidity differ significantly for type A and B dissections and depends on the type of therapy and the medical comorbidities of the patients. This is commonly associated with IMH, and rate of rupture is high. pp 51-60 | An aortic dissection can be considered chronic after 2 weeks, because mortality tends to level off at that time. Furthermore, only 50% to 70% will be alive 5 years after surgery depending on age and underlying cause. vii Foreword to the Second Edition It is a pleasure, an honor, and a distinct privilege to write the foreword for the second edition of Surgical Pathology Dissection: An Illustrated Guide. Type A is a more immediately life-threatening problem than is type B. J Thorac Cardiovasc Surg 122: 578–82, https://doi.org/10.1007/978-2-287-79929-7_4. Aging increases its incidence as degenerative aortic wall changes and the rate of systemic hypertension increase. Within 1 week, two thirds of patients die if untreated.5 Of these deaths, 75% occur in the first 2 weeks. Am J Cardiol 25: 411–5, Pyeritz RE (2000) The Marfan syndrome. Anatomically, two classification systems are used to describe aortic dissections. Patients who present with syncope are more likely to have a type A dissection than a type B; syncope is associated with cardiac tamponade, stroke, and death.8, In contrast, the mortality for type B dissections is initially about 10% to 12% for patients who can be treated medically. The causes of death and morbidity attributed to type A aortic dissection included rupture of the ascending aorta causing cardiac tamponade, myocardial ischemia or infarction when the dissection involves the coronary ostia, heart failure caused by acute AR, stroke caused by malperfusion of the aortic arch branch vessels, mesenteric malperfusion causing renal failure or ischemic bowel, or limb ischemia.20 Aortic dissection can also rupture into the right atrium, the right ventricle, or the left atrium causing intracardiac shunting with congestive heart failure. Ann Vasc Surg 9: 311–23, Carlson RG, Lillehei CW, Edwards JE (1970) Cystic medial necrosis of the ascending aorta in relation to age and hypertension. ScienceDirect ® is a registered trademark of Elsevier B.V. ScienceDirect ® is a registered trademark of Elsevier B.V. URL: https://www.sciencedirect.com/science/article/pii/B9780323057264000330, URL: https://www.sciencedirect.com/science/article/pii/B978032308500700031X, URL: https://www.sciencedirect.com/science/article/pii/B9780323478700000568, URL: https://www.sciencedirect.com/science/article/pii/B0443065578501921, URL: https://www.sciencedirect.com/science/article/pii/B9781416032069100291, URL: https://www.sciencedirect.com/science/article/pii/B9780323511490000225, URL: https://www.sciencedirect.com/science/article/pii/B9781416037866100178, URL: https://www.sciencedirect.com/science/article/pii/B9780323567169000138, URL: https://www.sciencedirect.com/science/article/pii/B9780128017395000106, URL: https://www.sciencedirect.com/science/article/pii/B9780128099797000298, Comprehensive Vascular and Endovascular Surgery (Second Edition), Haytham Elgharably, ... Eric E. Roselli, in, Office Practice of Neurology (Second Edition), Peter M. Schulman MD, Rondall Lane MD, in, Enrique J. Pantin MD, Albert T. Cheung MD, in, Elizabeth A. Valentine MD, E. Andrew Ochroch MD, MSCE, in, Essentials of Cardiac Anesthesia for Noncardiac Surgery, Clinical Applications for Next Generation Sequencing in Cardiology, Joanna Ponińska, ... Zofia T. Bilińska, in, Clinical Applications for Next-Generation Sequencing, New Approaches to Aortic Diseases from Valve to Abdominal Bifurcation, The Journal of Thoracic and Cardiovascular Surgery, European Journal of Vascular and Endovascular Surgery. When uncomplicated, it is less lethal, with reasonable survival rates in medically treated patients. Part of Springer Nature. The small size and number of vessels in the midthoracic region often are invoked to explain the high incidence of ischemia in this region of the spinal cord compared with others. If the blood-filled channel ruptures through the outside aortic wall, aortic dissection is often fatal.Aortic dissection is relatively uncommon. Joanna Ponińska, ... Zofia T. Bilińska, in Clinical Applications for Next-Generation Sequencing, 2016, Arrhythmogenic right-ventricular cardiomyopathy, Catecholaminergic polymorphic ventricular tachycardia, Familial thoracic aortic aneurysms and dissections, Multiplex ligation-dependent probe amplification, Quantitative real-time polymerase chain reaction, Thoracic aortic aneurysms and dissections, Debabrata Dash, in New Approaches to Aortic Diseases from Valve to Abdominal Bifurcation, 2018.
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