Table Of Contents

Aortic Disease Overview

Watch ▶Aortic dissections and aneurysms: Pathology review

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Watch ▶Aortic dissection: Clinical sciences

Traumatic Aortic Rupture

• Commonly occurs due to trauma and/or deceleration injury
• Most commonly at aortic isthmus (proximal descending aorta just distal to origin of left subclavian artery).
• Common symptoms include tachycardia, and hypotention (hemorrhagic shock).
  • In hypotensive patients, systolic blood pressure is generally kept at <100 mm Hg to prevent injury extension and rebleeding while awaiting emergent operative repair.
• CXR may also show left-sided effusion due to hemothorax (this can also happen in aortic dissection)

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Diagnosis

• Chest x-ray is the initial screening test for suspected blunt aortic trauma
  • May reveal widened mediastinum.
    • Abnormal enlargement of the mediastinum seen on imaging studies such as chest x-rays and CT scans.
      • Caused by various conditions, e.g., aortic aneurysm, thymoma, lymphadenopathy, and traumatic injuries.
  • Should be used to rule out aortic injury in patients with blunt deceleration trauma (MVA or fall from > 10 feet)
• Confirm via CT Scan or TTE

• Other Widened mediastinum pictures

Aortic Dissection

General

• Aortic dissection involves a tear in the intimal layer of the aorta, leading to separation of the aortic wall layers.
• It is classified into two Stanford types:
  • Type A
    • Involves the ascending aorta.
  • Type B
    • Involves the descending aorta distal to the subclavian artery.

Risk Factors

• Aortic diseases

  • Hypertension (Strongest risk factor)
  • Thoracic aortic aneurysm
  • Atherosclerosis

• Connective tissue disorders (Marfan syndrome, Ehlers-Danlos syndrome)

  <aside> 💡

  Marfan is common cause for dissection in younger patients <40 🆚 HTN >60

  </aside>

• Structural abnormalities (bicuspid aortic valve, Turner syndrome)

• Inflammatory conditions (syphilis aortitis)

Clinical Features

• Pain
  • Severe chest pain often described as tearing or ripping, frequently radiating to the back.
• Asymmetric Blood Pressure:
  • Difference > 20 mm Hg between arms.
• Initial Findings may include a widened mediastinum on chest X-ray.

Diagnosis

• X-Ray is the initial test for suspected aortic dissection → shows widened mediastinum, aortic knob [A]

  

  [A]

• CT angiography (CTA) is the test of choice in hemodynamically stable patients.

  

  • Another imaging
  • Transesophageal echocardiography (TEE)
    • In hemodynamically unstable patients
    • Those with contraindications to CT (e.g., chronic kidney disease, contrast allergy).

Management

• General Measures
  • Maintain heart rate < 60 bpm and systolic blood pressure between 100-120 mmHg.
    • First-line ⇒ Intravenous beta-blockers (e.g., esmolol, labetalol).
    • Nitroprusside can be added if blood pressure remains elevated.
  • IV opioid analgesia
• Definitive Measures
  1. Type A Dissection
     • Surgical emergency requiring immediate intervention.
  2. Type B Dissection
     • Initially managed medically unless complications develop or the dissection progresses.
     • Options include endovascular or open surgical repair.

Complications

• Type A (Ascending +/- Descending) Complications
  • Caused by Extension of the aortic dissection
  • Potential for myocardial infarction, stroke, aortic regurgitation, cardiac tamponade, Horner's syndrome, vocal cord paralysis.
• Type B (Descending only) Complications
  • Risk of limb, renal, or mesenteric ischemia.
• Acute aortic dissection