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Acute Aortic Syndrome (AAS): A High-Risk Missed Diagnosis in the Emergency Department

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The High-risk Surgical Patient

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Abstract

Acute aortic syndrome (AAS) is a pathological condition including aortic dissection (AD), intramural hematoma (IMH), and penetrating aortic ulcer (PAU).

These three pathologies have similar clinical presentations, with chest pain as the main symptom, and they are associated to an high risk of aortic rupture, with an high morbidity and mortality.

The incidence of AAS is relatively low (2.6–3.5 cases/100,000/year), but their higher mortality and their frequent misdiagnosis or delay in diagnosis make necessary to know and to apply in the emergency department specific diagnostic and surgical algorithms. CT scan is the exam of choice in emergency to reach the diagnosis and to choose the appropriated treatment for patients, according to his peculiar clinical, anatomical, and radiological features.

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Notes

  1. 1.

    Patients with congenital disease can show the onset of AAS symptoms at very praecox age: in Loeys–Dietz syndrome, the middle age for the first aortic dissection is 26, in Ehlers–Danlos, the first vascular signs can be found at an average of 23. Other congenital diseases (such Turner or Marfan syndrome) show the first pathologic signs in aorta lately, but always decades before people with atheromasic etiology of disease [7].

  2. 2.

    Chest trauma with rapid deceleration, typical of motor vehicle accidents, can produce aortic injury or even complete rupture. The aortic isthmus is generally involved because here ascending aorta and arch become relatively fixed to the thoracic cage [6, 8].

  3. 3.

    “Classical ADs”: aortic dissection not associated to connective congenital degenerative disease.

  4. 4.

    Park et al. found that 73% of patients treated in open surgery for an IMH in the proximal aorta and diagnosed by CT scan were affected by ADs, with a small entry tear that spontaneously had sealed [12, 19].

  5. 5.

    It is necessary to distinguish between blood pools and Ulcers Like Projection (ULP). The former has a very narrow intimal orifice, usually communicate with a lumbar or intercostal artery, and have no communication with the true lumen; the latter appear at CT scan as localized contrast filled pouch that communicates with the true lumen [20].

  6. 6.

    International Registry of Acute Aortic Dissections.

  7. 7.

    There is no strong evidence suggesting the best blood pressure target for dissections or IMH, but most guidelines propose a SBP target of 100–120 mmHg.

  8. 8.

    Flow mainly perpendicular to the direction of bulk flow in the descending thoracic aorta.

  9. 9.

    dP/dT: rate of rise of left ventricular pressure; dP/dt(max): is the maximal rate of rise of (usually) left ventricular pressure (LVP), but it is determined by myocardial contractility and the loading conditions on the ventricle, thus it is an imperfect and sometimes incorrect predictor of the inotropic state.

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Author information

Authors and Affiliations

  1. Vascular Surgery, ASST Vimercate, Vimercate, Italy

    Paola Tracanelli

  2. Dipartimento di Emergenza Urgenza, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy

    Paolo Aseni

  3. Department of Biomedical and Clinical Sciences “L. Sacco”, Università degli Studi di Milano, Milan, Italy

    Paolo Aseni

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  1. Paola Tracanelli
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Editor information

Editors and Affiliations

  1. Dipartimento di Emergenza Urgenza, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy

    Paolo Aseni

  2. Divisione di Cardiochirurgia, IRCCS Fondazione Policlinico San Matteo, Pavia, Pavia, Italy

    Antonino Massimiliano Grande

  3. Div. of Emerg. Surg., Abdominal Center, Helsinki University Hospital Meilahti, Helsinki, Finland

    Ari Leppäniemi

  4. Department of Pathophysiology and Transplantation, General Surgery and Trauma Team, University of Milano, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy

    Osvaldo Chiara

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Tracanelli, P., Aseni, P. (2023). Acute Aortic Syndrome (AAS): A High-Risk Missed Diagnosis in the Emergency Department. In: Aseni, P., Grande, A.M., Leppäniemi, A., Chiara, O. (eds) The High-risk Surgical Patient. Springer, Cham. https://doi.org/10.1007/978-3-031-17273-1_19

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  • DOI: https://doi.org/10.1007/978-3-031-17273-1_19

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