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Ascending Aortic Dissection, Penetrating Aortic Ulcer, and Intramural Hematoma

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Diseases of the Aorta

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Abstract

Acute aortic dissection has been among the most lethal entities in the medical literature for centuries. The incidence of acute type A aortic dissection (ATAAD) is 3.5–6 in 100,000 but increases with age and demonstrates a male predominance. Risk factors in older adults include traditional cardiovascular risk factors, while younger patients are more likely to have a connective tissue disorder. Dissection begins as a tear in the intima and if it involves the ascending aorta or arch only it is classified as type A in the Stanford system. The Penn classification is used to assess the degree of organ system malperfusion present in dissection. Clinical presentation as well as biomarkers, such as D-dimer, is used for diagnosis, while confirmation is typically made with imaging including CT, TEE, and MR. Guiding principles of dissection management involve prompt recognition, transfer to intensive care for monitoring, and immediate impulse control – specifically reduction in heart rate, blood pressure, and LV ejection force, or dp/dt. Surgical repair is the mainstay of acute type A aortic dissection treatment, yet the optimal approach to surgery remains unknown. Diverse options include the extent of repair to be attempted (such as arch replacement or root replacement), use of hybrid endovascular modalities (such as frozen elephant trunk technique), cannulation site, and cerebral perfusion strategy. Other acute aortic syndromes include intramural hematoma (blood from the vasa vasorum infiltrates the medial layer) and penetrating atherosclerotic ulcer (plaque erodes through the internal elastic lamina into the media).

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Abbreviations

AI:

Aortic insufficiency

ARR:

Aortic root replacement

ATAAD:

Acute type A aortic dissection

AVAR:

Aortic valve and aorta replacement

AVR:

Aortic valve replacement

BAV:

Bicuspid aortic valve

CVA:

Cerebrovascular accident

DHCA:

Deep hypothermic cardiac arrest

FET:

Frozen elephant trunk technique

GERAADA:

German Registry for Acute Aortic Dissection Type A

IRAD:

Internal Registry of Acute Aortic Dissection

MHCA:

Moderate hypothermic cardiac arrest

MI:

Myocardial infarction

MPS:

Malperfusion syndrome

ND:

Neurologic deficit

PE:

Pulmonary embolism

SACP:

Selective antegrade cerebral perfusion

SCAR:

Supracoronary ascending aorta replacement

SCI:

Spinal cord injury

STEMI:

ST-elevation myocardial infarction

TAR:

Total arch replacement

TEE:

Transesophageal echocardiogram

TTE:

Transthoracic echocardiogram

VSAR:

Valve-sparing aorta replacement

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Authors and Affiliations

  1. Leon H. Charney Division of Cardiology, NYU School of Medicine, New York, NY, USA

    Rebecca Pinnelas

  2. Medicine (Cardiology), Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai, New York, NY, USA

    Prashant Vaishnava

  3. Internal Medicine, Frankel Cardiovascular Center, University of Michigan Health System, Ann Arbor, MI, USA

    Kim A. Eagle

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  1. Rebecca Pinnelas
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  2. Prashant Vaishnava
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  3. Kim A. Eagle
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Editors and Affiliations

  1. Interventional Cardiology, Vascular and Endovascular Medicine, Loyola University Medical Center, Maywood, IL, USA

    Robert S. Dieter

  2. Cardiovascular and Thoracic Surgery, Northwestern University at Cadence Health Emeritus, Winfield, IL, USA

    Raymond A. Dieter Jr.

  3. University of Tennessee Medical Center, Cardiovascular and Thoracic Surgery, Knoxville, TN, USA

    Raymond A. Dieter III

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Pinnelas, R., Vaishnava, P., Eagle, K.A. (2019). Ascending Aortic Dissection, Penetrating Aortic Ulcer, and Intramural Hematoma. In: Dieter, R., Dieter Jr., R., Dieter III, R. (eds) Diseases of the Aorta . Springer, Cham. https://doi.org/10.1007/978-3-030-11322-3_9

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