Diagnosis and Management of Acute Type A Aortic Dissection

Abstract

Acute aortic dissection (AAD) is the most common aortic catastrophe. The mortality rate of type A dissection approaches 40% to 50% in 48 hours. Causes of death include rupture, aortic insufficiency, or malperfusion involving the coronary arteries, head vessels, visceral arteries, and lower extremities. Other acute aortic conditions can be confused with AAD. Emergent surgery is usually recommended, although there are some situations in which initial management of malperfusion or conservative therapy can be considered prior to proximal aortic repair. Various surgical techniques are employed to manage AAD. This article reviews the etiology, clinical presentations, and management of patients with type A AAD.

Type A Aortic Dissection Complicated by an Aorto-Right Atrial Fistula

“…In this review, the fistula was diagnosed preoperatively in 80% of the cases. This was accomplished most commonly by aortography prior to 1990, which reflects the diagnostic modality of choice during that era for patients suspected of having an aortic dissection . Aortography also facilitates evaluation of the coronary anatomy, assesses the severity of aortic valve insufficiency, and identifies complications such as an ARHF.…”

“…Aortography also facilitates evaluation of the coronary anatomy, assesses the severity of aortic valve insufficiency, and identifies complications such as an ARHF. However, aortography is no longer considered a primary diagnostic modality for the diagnosis of thoracic dissection due to the time‐consuming and invasive nature of the investigation . In the modern era, only 4% of patients suspected of having an aortic dissection undergo aortography initially, whereas 50% undergo CT, 42% echocardiography, and 1% MRI …”

“…CT has emerged as the diagnostic modality of choice for patients with suspected aortic dissection due to its widespread availability, rapid image acquisition, and ability to detect the presence of the dissection with high sensitivity and specificity . CT demonstrates the proximal and distal extent of the dissection and which visceral arteries arise from the true and false lumens; however, it is unable to provide functional information about the heart and the diagnostic utility in identifying complications such as ARHF is limited . Therefore, in patients diagnosed with a dissection by CT, the presence of risk factors for an ARHF (previous cardiac surgery, murmur, or heart failure) should prompt further investigation with echocardiography.…”

Medical management of acute type a aortic dissection in association with early open repair of acute limb ischemia may prevent aortic surgery

“…The Stanford classification subclassifies the aortic dissections into 2 types. Type A involves the ascending aorta (DeBakey types I and II), but type B does not (DeBakey type III) [1]. The estimated total incidence of acute (type A and B) dissection is 30 to 43 per 1 million population per year.…”

“…The operative mortality, though, is about 10–20%. This percentage is higher in several subsets of patients, including those with severe neurologic deficits and advanced malperfusion [1,3]. …”