32 - Acute Aortic Syndromes

Abstract

Acute aortic syndrome can occur in patients with no known cardiac or aortic disease, but it more often occurs in patients with underlying conditions that are associated with an increased risk of aortic aneurysm and dissection. The most common type of acute aortic syndrome is aortic dissection, followed by aortic intramural hematoma (IMH), penetrating ulcer in the aortic wall, and traumatic aortic injury. Patients with aortic dissection can present with severe chest or back pain, hypotension, and shock. Dissections can cause pericardial tamponade, aortic regurgitation, acute infarction, and aortic rupture. IMH can progress to frank dissection with an intimal flap and aortic rupture. The atherosclerotic plaque of a penetrating ulcer can disrupt the aortic wall’s elastic lamina, often with a localized IMH. Blunt thoracic trauma can cause aortic dissection or transection. Diagnosis is based on the clinical history, physical examination findings, and serum D-dimer measurements. Computed tomographic angiography (CTA) is used initially for assessment. Bedside transthoracic echocardiography followed by transesophageal echocardiography is recommended only if CTA is not available or is contraindicated because of patient instability or a contrast allergy. Depending on the diagnosis, management includes blood pressure control and prompt surgical intervention with graft replacement.