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Dx and Mx Acute Thoracic Aortic Dissection (Predisposing conditions…
Dx and Mx Acute Thoracic Aortic Dissection
Predisposing conditions
Thoracic trauma (deceleration injury, weight lifting, other valsalva)
Connective tissue disease (marfan's, Loeys-Deitz synd, Turner syndrome (bicuspid AV, coarc aorta and dilation ascending thoracic aorta), Ehlers Danlos synd.
Familial thoracic aortic syndrome (genetic mutations)
Bicuspid aortic valve
Inflammatory diseases associated (Takayasu arteritis, Giant cell arteritis, Behcet disease, Ank Spond)
Autosomal dominant polycystic kidney disease
Noonan syndrome
Recent aortic manipulation (surgical, catheter)
HTN - including phaeochromocytoma, cocaine
Pregnancy
Chronic corticosteroid or immunosuppression agent
Presentation
Chest, back or abdominal pain
abrupt onset, severe, ripping/tearing/stabbing/sharp
syncope
Perfusion deficit: limb, CNS, myocardial
Exam
Pulse deficit
Different BP in limbs
Focal neurological deficit
New aortic regurg murmur
Diagnosis
ECG - exclude/treat AMI
Imaging
Definitive identification or exclusion
Most appropriate choice depends on: Patient factors (HD stability, renal fx, contrast allergy), Institution factors (rapid availability, technology, expertise)
CXR - evaluation/screening for dilated aorta or bleeding, also can identify other causes for pts symptoms
CT - Measure external aortic diameter (widely available, good identification, ix other disease processes, determine type of dissection, plan for surgery)
MRI - Sensitive, specific, anatomic variants, no radiation/contrast BUT remote, prolonged
Echo - measure internal aortic diameter - may underestimate if intraluminal clot, wall inflammation
Management
Initial management
Directed at decreasing aortic wall stress by controlling HR and BP
IV BB
Calcium channel blocker
+/- other antihypertensive (after rate control, avoid reflex tachy)
Surgical consult
For all incase
If ascending aorta involved: likely surgery
If descending aorta involved, medical mx unless life threatening complications (progression of extension, enlarging aneurysm, uncontrollable BP)
Ongoing management
Ongoing HTN management
Lipid profile optimisation
Smoking cessation
Other atherosclerotic risk reduction
Avoid strenuous lifting
Anatomy
Thoracic aorta divided into 4 parts:
Aortic root (includes aortic valve annulus, aortic valve cusps and sinuses of Valsalva)
Ascending aorta (sinotubular jn to brachiocephalic artery)
Aortic arch (brachicephalic artery to isthmus)
Descending aorta (from isthmus btw origin of left subclavian artery and ligamentum arteriosum into abdomen)