Aortic dissection: Info & specialists for aortic dissection

14.11.2023
Leading Medicine Guide Editors
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Leading Medicine Guide Editors

Aortic dissection is a splitting (dissection) of the wall layers of the aorta. The aorta is the main artery that carries blood from the heart to the body. Aortic dissection causes blood to leak from the aorta into the spaces between the vessel walls. Symptoms depend on the location and extent of the dissection.

More information about causes and treatment options, as well as selected aortic dissection specialists, can be found below.


ICD codes for this diseases: I71.00, I71.01, I71.02, I71.03, I71.04, I71.05, I71.06, I71.07

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Brief overview:

  • What is an aortic dissection? A splitting of the wall layers of the aorta (Arteria maxima) that allows blood to leak from the vessel into the vessel wall layers and obstructs blood flow.
  • Risk factors: Various pre-existing conditions can cause the disease, such as arteriosclerosis high blood pressure, heart valve abnormalities but also older age and previous injuries to the vascular wall.
  • Symptoms: Typically, there is a sudden onset of severe chest pain radiating to the shoulder and back. Other complaints depend on the location and extent of the dissection.
  • Types: According to the Stanford classification, the classification of an aortic dissection depends on the point of entry of the blood into the regular vessel. The treatment is also based on this.
  • Diagnostics: If this is suspected, imaging procedures such as X-rays, ultrasound, CT and MRI as well as angiography provide information about what is happening in the abdominal cavity.
  • Treatment: An acute dissection is an emergency and should be operated on immediately; a vascular prosthesis then replaces the damaged area of the aorta. Otherwise, doctors recommend close monitoring so that further steps can be taken if necessary.

Article overview

What is an aortic dissection?

A blood vessel is basically a tube through which blood flows. It is formed by the vessel wall. The wall of larger blood vessels consists of three layers of tissue lying on top of each other:

  • inner vascular layer (intima),
  • middle vascular layer (media) and
  • outer vascular layer (adventitia)

The cavity inside a vessel is called the lumen.

Splitting of the vessel wall layers occurs when the inner layer tears but the outer layer remains intact. Then blood from the lumen enters through the tear into the space between the two layers.

Due to the increased pressure in the aorta more and more blood enters the intermediate layer. This causes the layers to diverge over long distances and can form an unnatural gap. This allows the actual lumen to be completely closed.

The intima usually cannot withstand the high pressure and tears again at another point. This allows the blood to flow back into the aorta.

Aortendissektion
Illustration of an aortic dissection with blood in the interspace of the aortic vessel wall © htcmed | AdobeStock

Risk factors for aortic dissection

The following are considered risk factors for the development of aortic dissection arteriosclerosis and structural weakness of the media (mediadegeneration). Such a structural weakness is often seen in patients with congenital heart valve anomalies or connective tissue diseases. Corresponding diseases are, for example, Marfan syndrome or Ehlers-Danlos syndrome.

Other risk factors are an older age as well as high blood pressure. In addition, traumatic events can be the cause of an aortic dissection, such as an injury to the vessel wall during a catheter examination.

Symptoms of aortic dissection

The signs of the disease depend on the location and extent of the dissection. Some patients with chronic aortic dissection have no symptoms at all. In others, sudden cardiac death can occur in extreme cases when the aorta ruptures.

Typically, an acute aortic dissection manifests itself by a sudden, sharp, stabbing or tearing pain in the chest. It can radiate to the shoulder blades and back.

Depending on the affected section of the vessel, other symptoms may occur, such as

The blood loss may cause symptoms of shock, such as

  • Accelerated pulse,
  • Drop in blood pressure,
  • Impaired consciousness.

Types of aortic dissection

Depending on the location of the tear and the extent of the bleeding, several categories can be distinguished. The DeBakey classification defines three types of aortic dissection:

  • DeBakey I: Tear in the area of the ascending aorta (aorta ascendens), the bleeding extends beyond the aortic arch.
  • DeBakey II: Rupture also in the ascending aorta, but re-entry of bleeding still occurs in the ascending aorta.
  • DeBakey III: Entry and re-entry are in the descending aorta.

A further development is the Stanford Classification. It distinguishes only two types based on the localisation of the entry:

  • Stanford A (= DeBakey I and II): Tear in the ascending aorta,
  • Stanford B (= DeBakey III): Tear in the descending aorta.

The location of the tear is decisive for the patient's risk and thus for the treatment. Therefore, aortic dissection specialists mainly use the Stanford types to assess the disease.

Diagnosis of aortic dissection

If an aortic dissection is suspected, imaging can show bleeding in the aorta. First indications can be

  • the X-ray image of the thorax with its organs and
  • the ultrasound examination (Sonography) of the abdominal cavity

The transesophageal echocardiography (TEE, ultrasound examination via the oesophagus) enables a precise assessment of the aorta near the heart and the descending aorta.

Doppler technology also allows differentiation of the normal and "false" lumen, entry and re-entry can usually be detected. Contrast-enhanced computer tomography (CT) provides good visualisation of the extent and relationship of the aortic dissection to the adjacent vessels. Magnetic resonance imaging (MRI) is also a reliable method for diagnosing aortic dissection. Angiography (method of imaging the vessels) can also provide important insights.

Treatment of aortic dissection

The location of the tear is decisive for the treatment.

An acute Stanford A-type dissection must be considered an emergency and should be operated on as soon as possible. The affected section of the vessel is usually removed and replaced by a vascular prosthesis.

The implantation of vascular prostheses in the aorta means a relatively high risk for the patient. That is why a Stanford B type dissection is initially treated with a wait-and-see approach. This means that the doctor observes the development of the dissection. Only when the situation deteriorates, for example in the case of

  • threatened occlusion of vascular outlets,
  • rapidly increasing vessel diameter or
  • threatened rupture of the aorta,

is treatment initiated.

Complications such as blocked vessel outlets are treated by aortic dissection specialists using catheters. By means of Stent implantation the vessel wall can be stabilised and, if necessary, an artificial re-entry can be created. This reduces the pressure in the "false lumen" and thus reduces the risk of rupture.

The treatment of the pain and the lowering of the blood pressure is carried out using medication.

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