Acute Aortic Syndromes: Update in Current Medical Management

Abstract

Advances in medical therapy and non-surgical percutaneous options to manage the specter of acute aortic syndromes have improved both patient morbidity and mortality. There are key features in the patient history and initial exam which physicians should be attuned to in order to diagnose acute aortic syndromes such as aortic dissection, penetrating aortic ulcer, and intramural hematoma. Once recognized, early initiation of the appropriate pharmacologic therapy is important, and further appreciating the limitations of such therapy before considering a surgical approach is critical to improve patient outcomes. For the undifferentiated patient with acute aortic dissection presenting to facilities who do not routinely manage this condition, adding pharmacologic agents in the correct sequence assures the best chance for a satisfactory outcome.

Antithrombotic therapy in abdominal aortic aneurysm: beneficial or detrimental?

“…Development of an intramural hematoma within the wall of the aorta constitutes a true acute aortic syndrome with treatment similar to ruptured AAAs with published data showing anticoagulants are detrimental and may precipitate IHM in this clinical scenario. 82,83 Conversely, other studies have shown enzymes such as MMP-9 are inhibited by FXa antagonists, low-molecular-weight heparin, and vitamin K antagonist use and may promote sac integrity surrounding a stent in a type II endoleak. 80,84 Nonocclusive mural thrombus and aortic wall stability…”

Acute aortic syndromes and aortic emergencies

“…Type A affects ascending aorta and arch and may result in occlusion of coronary vessels, incompetence of aortic valve or rupture into the pericardial space. Type A AAS (AD, IMH, and PAU) and aortic emergencies carry a high risk of mortality with conservative management and are treated with emergent surgical intervention (1,5,(18)(19)(20). Type B abnormalities commence distal to the origin of the left subclavian artery and uncomplicated type B ADs can be managed by a more conservative approach with medication and/or EVAR, due to a significantly higher mortality after open repair (1,4,21,22).…”

“…Type A AAS (AD, IMH, and PAU) and aortic emergencies carry a high risk of mortality with conservative management and are treated with emergent surgical intervention (1,5,(18)(19)(20). Type B abnormalities commence distal to the origin of the left subclavian artery and uncomplicated type B ADs can be managed by a more conservative approach with medication and/or EVAR, due to a significantly higher mortality after open repair (1,4,21,22). Complicated type B dissections with organ or limb malperfusion, progressive dissection, intractable pain, or uncontrolled hypertension are managed by a more invasive approach, preferably EVAR (5).…”

“…The term acute aortic syndrome (AAS) encompasses three pathological entities; aortic dissection (AD; 85-95% of AAS), penetrating aortic ulcer (PAU; 2-7%) and intramural hematoma (IMH; 0-25%) (1). Even though other conditions that represent aortic emergencies like trauma, iatrogenic/septic pseudoaneurysms, and ruptured atherosclerotic aneurysm have similar signs and symptoms, the term AAS is typically reserved for the aforementioned triad of AD, PAU and IMH entities.…”

“…These conditions are relatively uncommon (AAS incidence of 3.5 to 6.0 per 100,000 patient/years); but carry a high mortality rate (80-90% for aortic trauma and 50-60% for type A AD) (3)(4)(5). Rapid, accurate recognition and classification of AAS and aortic emergencies is, therefore, necessary (1,6). Treatment often entails a multidisciplinary approach involving medical, endovascular and surgical interventions.…”