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Acute aortic syndromes 

Acute aortic syndromes

Chapter:
Acute aortic syndromes
Author(s):

Andrew R.J. Mitchell

, James D. Newton

, and Adrian P. Banning

DOI:
10.1093/med/9780199204854.003.161401_update_001

Update:

Intramural haematoma and penetrating atherosclerotic ulcers are included in the classification of acute aortic syndromes. Intramural haematoma is characterized by the absence of a dissection flap and is often a prelude to aortic dissection and is usually managed surgically when affecting the ascending aorta. Penetrating atherosclerotic ulceration can be effectively managed by endovascular stenting.

Updated on 29 Oct 2015. The previous version of this content can be found here.
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date: 28 March 2017

The acute aortic syndromes are acute dissection, intramural haematoma, and penetrating ulcer, and all involve disruption of the wall of the aorta with potentially devastating consequences. Although relatively uncommon, left unrecognized and untreated they can carry a mortality rate of up to 2% per hour and 50% within the first few weeks.

Clinical presentation—the pain of an acute aortic syndrome is typically of instantaneous onset, cataclysmic in severity, pulsatile and tearing in quality, located either in the anterior thorax or back, and migrating if a dissection extends through the thorax. Patients usually appear shocked, but blood pressure may be normal or raised and heart rate relatively slow. Physical signs typically reflect the region of the aorta involved and effects of pressure on adjacent structures: evidence of new aortic regurgitation or development of pulse deficits should be actively sought.

Diagnosis—abnormalities on the chest radiograph and ECG are common, but neither investigation is diagnostic and further imaging is always necessary by MRI, contrast-enhanced CT, or transoesophageal echocardiography, depending on local availability and the clinical condition of the patient.

Management—every patient with a clinical suspicion of an acute aortic syndrome should receive effective pain relief and antihypertensive medication (intravenous labetalol or esmolol), aiming to maintain systolic blood pressure <120 mmHg. For confirmed intramural haematoma or dissection of the ascending aorta (type A), emergency surgery is indicated. Penetrating ulcers can be treated with endovascular stenting. When the ascending aorta is spared (type B), aggressive control of blood pressure is the usual initial management, with surgery being considered if there is evidence of further progression of dissection or ischaemic complications. In the long term, strenuous efforts to control blood pressure are indicated for all patients who have survived aortic dissection, with repeat imaging at least once a year.

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