Acute Aortic Syndromes and Thoracic Aortic Aneurysm

Abstract

Acute and chronic aortic diseases have been diagnosed and studied by physicians for centuries. Both the diagnosis and treatment of aortic diseases have been steadily improving over time, largely because of increased physician awareness and improvements in diagnostic modalities. This comprehensive review discusses the pathophysiology and risk factors, classification schemes, epidemiology, clinical presentations, diagnostic modalities, management options, and outcomes of various aortic conditions, including acute aortic dissection (and its variants intramural hematoma and penetrating aortic ulcers) and thoracic aortic aneurysms. Literature searches of the PubMed database were conducted using the following keywords: aortic dissection, intramural hematoma, aortic ulcer, and thoracic aortic aneurysm. Retrospective and prospective studies performed within the past 20 years were included in the review; however, most data are from the past 15 years. and studied by physicians for centuries. Descriptions of such pathologic conditions of the aorta as aneurysm and dissection date back as early as the 2nd century during the time of Galen, whose discoveries were largely made through studies of apes. More "recent" reports were described by Vesalius in 1557, followed by Nichols in 1732, who detailed the process of aortic dissection. In 1761, Morgagni reported detailed pathologic features of a patient with a ruptured aorta. 1 However, our true understanding of aortic pathology began with the dissertation by Shennan 2 in 1934, which included a description of penetrating atheromatous plaques of the thoracic aorta. His report was followed by the first successful management of aortic dissection by DeBakey in 1955. 1 Since then, our knowledge of the pathologic conditions of the aorta has grown considerably and continues to evolve with ongoing research into the pathophysiology of these conditions, technological advances in the modes of detection, and improved therapeutic options. Clinical databases, such as the International Registry of Acute Aortic Dissection (IRAD), the largest current registry for acute aortic syndromes, have also contributed tremendously to our knowledge of acute aortic pathology.For the practicing clinician, knowledge of aortic disease is paramount because patients with aortic conditions contribute significantly to the overall mortality from cardiovascular disease. This review discusses the pathophysiology, epidemiology, presentation, diagnosis, and therapeutic options for several forms of acute and chronic aortic pathology: aortic dissection (including its variants intramural hematoma [IMH] and penetrating atheromatous aortic ulcer) and thoracic aortic aneurysm (TAA). Literature searches were performed of the PubMed database using the following key words: aortic dissection, intramural hematoma, aortic ulcer, and thoracic aortic aneurysm. Retrospective and prospective studies conducted within the past 15 years, along with some data from years prior, were included in this review.

Typ-A-Dissektion

“…Die Klassifikation nach Stanford hat sich gegenüber den Klassifikationen nach DeBakey und Svensson durchgesetzt, da sie einfacher und genauer Rückschlüs se auf die Prognose sowie die therapeuti schen Konsequenzen erlaubt [42].…”

“…3,5/100.000 Ein wohner; ca. 62% aller Aortendissektionen werden als TypADissektion klassifiziert [42]. Vermutlich 20% aller Patienten ver sterben, bevor sie ein Krankenhaus errei chen [19].…”

“…Wesentlich seltener lassen sich Synkopen, wandernde oder abdo minelle Schmerzen als Initialsymptom beob achten ( [23,42,50]; . Tab.…”

“…Die Sensitivität der MRT, CT und TEEUntersuchung für eine TypA Dissektion liegt bei ca. 95% [19,42]. Wenn ein Untersuchungsverfahren bei dringen dem Verdacht auf eine Aortendissektion die Diagnose nicht eindeutig verifizieren kann, sollte unbedingt ein weiteres dia gnostisches Verfahren angewendet wer den [37].…”

“…Es werden 30% aller Patienten mit einer Aortendissektion initial fehldiagnosti ziert [42]. Thorakale Schmerzen verleiten zu der Diagnose eines akuten Koronar syndroms (ACS) insbesondere dann, wenn von der Dissektion ein Koronaros tium mitbetroffen ist, sich im Elektrokar diogramm (EKG) ischämietypische Ver änderungen und in den Laboruntersu chungen erhöhte kardiale Biomarker im Serum nachweisen lassen.…”