Aortic Dissection: Warning Signs, Urgent Care & Outcomes

What is Aortic Dissection?

Aortic dissection is a serious condition that occurs when the inner layer of the aorta, called the intima, tears. This tear allows blood to flow between the layers of the aortic wall, causing separation (dissection) between the layers of the aortic wall. As a result, blood flow through the aorta is disrupted, which can lead to life-threatening complications if not treated promptly. The aorta is the largest artery in the body, originating from the heart's left ventricle and extending down through the chest and abdomen. It is responsible for supplying oxygenated blood to the entire body. When an aortic dissection occurs, it can compromise blood flow to vital organs, leading to organ damage or failure.

Causes of Aortic Dissection

Several factors can contribute to the development of an aortic dissection. The most common predisposing factor is long-standing uncontrolled high blood pressure, which increases wall stress and predisposes the aorta to tearing.

Other aortic dissection causes include:

• Connective tissue disorders: Genetic conditions like Marfan syndrome and Ehlers-Danlos syndrome can weaken the aortic wall, making it more susceptible to tearing.
• Bicuspid aortic valve: This congenital heart defect, where the aortic valve has only two leaflets instead of the normal three, can lead to increased stress on the aortic wall.
• Trauma: Blunt chest trauma, such as from a car accident, can cause an aortic dissection.
• Atherosclerosis: The build-up of plaque can contribute to degenerative changes in the aortic wall, though it is a less common direct cause of dissection.
• Inflammatory or infectious aortitis: Rare conditions such as giant cell arteritis, Takayasu arteritis, or tertiary syphilis can inflame and weaken the aortic wall increasing the risk of dissection.

Types of Aortic Dissection

Aortic dissections are classified based on their location and extent. The Stanford classification system is commonly used, which divides dissections into two types:

1. Type A aortic dissection: This type involves the ascending aorta, the portion of the aorta that rises from the heart and arches towards the head. Type A dissections are more common and often require emergency surgery.
2. Type B aortic dissection: This type involves the descending aorta, the portion that runs down through the chest and abdomen. Type B dissections are generally managed medically unless complications such as rupture, malperfusion, or persistent pain develop, depending on the severity and presence of complications.

Risk Factors of Aortic Dissection

Certain factors can increase your risk of developing an aortic dissection. These include:

• High blood pressure: Uncontrolled hypertension is the most significant risk factor for aortic dissection.
• Age: The risk increases with age, particularly for those over 60.
• Gender: Men are more likely to experience aortic dissections than women.
• Family history: Having a first-degree relative with a history of aortic dissection or thoracic aortic aneurysm increases your risk.
• Connective tissue disorders: Genetic conditions like Marfan syndrome and Ehlers-Danlos syndrome can weaken the aortic wall.
• Bicuspid aortic valve: This congenital heart defect can lead to increased stress on the aortic wall.
• Cocaine use: The use of cocaine can temporarily raise blood pressure and increase the risk of aortic dissection.
• Pregnancy: Rarely, pregnancy can increase the risk of aortic dissection, especially in women with connective tissue disorders.

Warning Signs & Symptoms of Aortic Dissection

Recognising the warning signs of an aortic dissection is crucial for seeking prompt medical attention. According to the Mayo Clinic, the most common symptom is sudden, severe chest pain, often described as a tearing or ripping sensation. This pain may be felt in the front or back of the chest and can radiate to the neck, jaw, arms, or back.

Other aortic dissection symptoms may include:

• Shortness of breath
• Weakness or paralysis on one side of the body
• Difficulty speaking or loss of vision
• Weak pulse in one arm compared to the other
• Sweating
• Nausea and vomiting
• Fainting or dizziness

It is essential to note that symptoms can vary depending on the location and extent of the dissection. Some individuals may experience milder symptoms or no pain at all, making diagnosis more challenging.

How Aortic Dissection is Diagnosed?

If an aortic dissection is suspected based on symptoms and physical examination, several diagnostic tests can confirm the diagnosis. These tests help visualise the aorta and determine the location and extent of the dissection.

The initial evaluation may include:

• Electrocardiogram (ECG): This test can help rule out a heart attack, which may present with similar symptoms.
• Chest X-ray: An X-ray can show a widened aorta or other signs suggestive of a dissection.
• Blood tests: D-dimer levels may support the diagnosis if elevated, although normal results do not exclude dissection. CBC and other labs help assess overall health and complications.

Tests to Diagnose Aortic Dissection

To confirm the diagnosis of an aortic dissection, imaging tests are essential. The most commonly used tests include:

1. Computed tomography (CT) angiography: This is the preferred imaging test for diagnosing aortic dissection. It uses X-rays and contrast dye to create detailed images of the aorta and can show the location and extent of the dissection.
2. Magnetic resonance imaging (MRI): An MRI uses powerful magnets and radio waves to create detailed images of the aorta. It can be used as an alternative to CT angiography, especially in patients with kidney problems or allergies to contrast dye.
3. Transoesophageal echocardiography (TEE): This test uses sound waves to create images of the heart and aorta from inside the oesophagus. It can provide detailed information about the dissection and is often used during surgery to guide treatment.

Emergency Treatment of Aortic Dissection

Aortic dissection treatment focuses on managing blood pressure, relieving pain, and preventing complications. The specific treatment approach depends on the type and severity of the dissection.

Medications

The initial management of an aortic dissection involves the use of medications to control blood pressure and heart rate. Intravenous beta-blockers (e.g., esmolol, labetalol) are first-line to reduce heart rate and shear stress, followed by vasodilators if needed to control blood pressure, are used to lower blood pressure and reduce the force of blood flow against the aortic wall. Pain medications may also be given to relieve discomfort.

Surgery

Type A aortic dissections almost always require emergency surgery to repair or replace the damaged portion of the aorta. The goal of surgery is to prevent the dissection from extending further, restore normal blood flow, and prevent complications such as aortic rupture or organ damage.

Surgery typically involves cardiopulmonary bypass to allow repair or replacement of the damaged aortic segment using a synthetic graft. to maintain circulation. The damaged section of the aorta is then repaired or replaced with a synthetic graft. In some cases, the aortic valve may also need to be repaired or replaced.

Endovascular Procedures

For complicated Type B dissections, thoracic endovascular aortic repair (TEVAR) is often preferred.. These minimally invasive procedures involve inserting a small tube (catheter) through an artery in the groin and guiding it to the site of the dissection. A stent-graft, a fabric-covered metal scaffold, is then deployed to cover the tear and redirect blood flow through the true lumen of the aorta.

Endovascular procedures are less invasive than open surgery and may be considered for patients who are not suitable candidates for surgery or have a lower risk of complications.

Complications of Aortic Dissection

Aortic dissection can lead to serious and life-threatening complications if not treated promptly. These complications include:

• Aortic rupture: If the dissection breaches the outermost adventitial layer, it can cause life-threatening internal bleeding, leading to massive internal bleeding and potentially death.
• Organ damage: Disrupted blood flow to vital organs, such as the brain, kidneys, or intestines, can cause organ damage or failure.
• Stroke: If the dissection involves the arteries that supply blood to the brain, it can cause a stroke.
• Cardiac tamponade: If the dissection causes blood to leak into the pericardial sac surrounding the heart, it can compress the heart and impair its ability to pump blood effectively.

Recovery and Long-Term Outlook for Aortic Dissection

The recovery process after aortic dissection treatment depends on the type of dissection and the treatment received. Patients who undergo surgery typically require a longer hospital stay and a more extensive recovery period compared to those who receive endovascular treatment. After discharge, patients require lifelong follow-up with periodic imaging to monitor the aorta and prevent recurrence or aneurysm formation with their healthcare team to monitor their recovery and manage any ongoing medical conditions.

Long-term management may include:

• Blood pressure control: Maintaining a healthy blood pressure through medications and lifestyle changes is crucial to prevent future dissections or complications.
• Imaging tests: Regular imaging tests, such as CT scans or MRIs, may be recommended to monitor the aorta and detect any changes or progression of the dissection.
• Lifestyle modifications: Adopting a heart-healthy lifestyle, including a balanced low-sodium diet, moderate physical activity (as advised), stress reduction, and avoidance of stimulants like cocaine or amphetamines, and avoiding smoking, can help promote overall cardiovascular health.

The long-term outlook for individuals who have experienced an aortic dissection varies depending on the type of dissection, the promptness of treatment, and the presence of complications. With appropriate medical management and follow-up care, many patients can achieve a good quality of life.

Prevention Tips

While not all aortic dissections can be prevented, there are steps you can take to reduce your risk:

• Manage high blood pressure: Keeping your blood pressure under control through medications, regular check-ups, and lifestyle changes can help reduce the strain on your aorta.
• Treat underlying conditions: If you have a connective tissue disorder or bicuspid aortic valve, work with your healthcare team to manage these conditions and monitor your aortic health.
• Avoid smoking: Smoking can damage your blood vessels and increase your risk of aortic dissection.
• Maintain a healthy weight: Obesity can contribute to high blood pressure and other cardiovascular risk factors.
• Wear a seatbelt: Always wear a seatbelt when driving or riding in a car to reduce the risk of traumatic aortic dissection in the event of an accident.

Conclusion

Aortic dissection is a life-threatening emergency that requires prompt recognition and treatment. Understanding the warning signs, such as sudden, severe tearing or ripping chest or back pain, and seeking immediate medical attention can significantly improve outcomes. Treatment for aortic dissection involves a combination of medications, surgery, and endovascular procedures, depending on the type and severity of the dissection. Long-term management of aortic dissection focuses on controlling blood pressure, monitoring the aorta, and adopting a heart-healthy lifestyle. By working closely with a healthcare team and following a comprehensive treatment plan, individuals who have experienced an aortic dissection can achieve a good quality of life.

If you or someone you know experiences symptoms suggestive of an aortic dissection, including severe chest pain or left side chest pain, it is crucial to seek emergency medical care immediately. Prompt diagnosis and treatment can make a significant difference in the outcome and long-term prognosis.

At Metropolis Healthcare, we recognise the urgency of accurate diagnostics when it comes to detecting and managing life-threatening conditions such as aortic dissection. With a presence across 750 towns in India, supported by over 220 laboratories, 4600+ service centres, and 10,000+ touchpoints, we ensure trusted and timely pathology services nationwide. Our expert team provides seamless at-home sample collection, while our advanced diagnostic technology delivers precise and reliable results for effective treatment planning.

FAQs

What is the difference between Type A and Type B aortic dissection?

Type A aortic dissections involve the ascending aorta, the portion closest to the heart, and typically require emergency surgery. Type B dissections involve the descending aorta and may be managed with medications and close monitoring, depending on the severity and presence of complications.

How fast can aortic dissection become fatal?

Aortic dissection can be rapidly fatal if not treated promptly. In some cases, aortic rupture can occur within hours of the onset of symptoms, leading to massive internal bleeding and potentially death. Seeking immediate medical attention is crucial for improving outcomes.

Can aortic dissection be prevented?

While not all aortic dissections can be prevented, managing risk factors such as high blood pressure, treating underlying conditions like connective tissue disorders, and maintaining a healthy lifestyle can help reduce the risk of developing a dissection.

What are the first signs to look for?

The most common sign of an aortic dissection is sudden, severe tearing chest pain that may radiate to the back, neck, or abdomen. Other signs and symptoms may include shortness of breath, weakness or paralysis on one side of the body, a weak pulse in one arm, and sweating.

How is aortic dissection treated long-term?

Long-term aortic dissection treatment focuses on managing blood pressure, monitoring the aorta for changes or progression, and promoting overall cardiovascular health through lifestyle modifications. Regular follow-up with a healthcare team is essential for detecting and managing any complications.

References

1. https://my.clevelandclinic.org/health/diseases/16743-aortic-dissection
2. https://www.mayoclinic.org/diseases-conditions/aortic-dissection/symptoms-causes/syc-20369496
3. https://doi.org/10.1016/S0140-6736(14)61005-9
4. https://doi.org/10.1093/eurheartj/ehu281
5. https://doi.org/10.4414/smw.2017.14489