Aortic dissection natural history, complications and prognosis: Difference between revisions

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{{Template:Aortic dissection}}
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{{CMG}}; '''Associate Editor-In-Chief:'''  {{CZ}}{{Sahar}}
{{CMG}}; '''Associate Editor-In-Chief:'''  {{CZ}}
 
==Overview==
==Overview==
[[Aortic]] dissection carries a very poor [[prognosis]]. 90% of patients who are untreated will be dead at one year. Type A dissection is associated with a worse [[prognosis]] than type B dissection. [[Aortic]] dissection can be complicated by extension to the [[coronary artery|coronary arteries]] resulting in [[myocardial infarction]], involvement of the [[aortic arch]] to cause [[stroke]], dilation of the route to cause [[aortic insufficiency]], extension into the [[pericardium]] to cause [[pericardial tamponade]], and [[heart failure]], and [[aortic rupture]].
The [[symptoms]] of aortic dissection usually develop in the fifth decade of life and start with [[symptoms]] such as sudden onset [[Chest pain|chest]]/[[back pain]]. If left untreated, [[patients]] with aortic dissection may progress to develop [[aortic regurgitation]], [[myocardial ischemia]], and [[cardiac tamponade]]. The [[complications]] of aortic dissection include but not limited to [[aortic rupture]], [[pericardial tamponade]], [[myocardial ischemia]], compression of nearby organs and etc. Aortic dissection carries a poor [[prognosis]]. [[Mortality rate]] differs based on the type of dissection and is higher in type A compared to type B (25% versus 12%).
 
== Natural History, Complications, and Prognosis ==
== Natural History ==
If the patient remains untreated, the [[mortality]] is:
* 1% per hour during the first day
* 75% at 2 weeks
* 90% at 1 year
 
==Complications==
The complications of aortic dissection include:
=== Cardiac===
====Aortic Rupture====
[[Aortic rupture]] leads to [[massive blood loss]], [[hypotension]] and [[shock]] often resulting in death. Indeed, [[aortic]] dissection accounts  for 3-4% of [[sudden deaths]].


====Pericardial Tamponade====
=== Natural History ===
[[Pericardial tamponade]] can occur due to extension of the dissection into the [[pericardium]].


====Acute Aortic Regurgitation====
*The [[symptoms]] of aortic dissection usually develop in the fifth decade of life and start with [[symptoms]] such as sudden onset [[Chest pain|chest]]/[[back pain]].<ref name="JuangBraverman2008">{{cite journal|last1=Juang|first1=Derek|last2=Braverman|first2=Alan C.|last3=Eagle|first3=Kim|title=Aortic Dissection|journal=Circulation|volume=118|issue=14|year=2008|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.108.799908}}</ref>
[[Acute aortic regurgitation]] due to the [[aortic]] [[dilation]] and dissection into the [[valve]] structure which can then cause [[acute]] [[pulmonary edema]]. [[Aortic insufficiency]] ([[AI]]) occurs in 1/2 to 2/3 of [[ascending aorta|ascending aortic]] dissections, and the [[heart sounds|murmur]] of [[aortic insufficiency]] is audible in about 32% of [[proximal]] dissections. The intensity (loudness) of the [[murmur]] is dependent on the [[blood pressure]] and may be inaudible in the event of [[hypotension]]. There are multiple [[etiology|etiologies]] for [[AI]] in the setting of [[ascending aorta|ascending aortic]] dissection. The dissection may dilate the annulus of the [[aortic valve]], so that the leaflets of the [[valve]] cannot close. Another mechanism is that the dissection may extend into the [[aortic root]] and detach the [[aortic valve]] leaflets. The third mechanism is that if there was an extensive [[intima]]l tear, the [[intima]]l flap may prolapse into the [[LV]] outflow tract, causing [[intima]]l [[intussusception]] into the [[aortic valve]] preventing proper [[valve]] closure.
*If left untreated, [[patients]] with aortic dissection may progress to develop [[aortic regurgitation]], [[myocardial ischemia]], and [[cardiac tamponade]].


====Myocardial Infarction====
===Complications===
[[Myocardial ischemia]] or [[myocardial infarction]] due to dissection into either the right or left [[coronary]] [[ostium]] (but most commonly the [[right coronary artery]]). [[Myocardial infarction]] ([[heart attack]]) occurs in 1-2% of [[aortic]] dissections. The [[etiology]] of the [[infarction]] is involvement of the [[coronary artery|coronary arteries]] (the [[artery|arteries]] that supply the heart) in the dissection. The right [[coronary artery]] is involved more commonly than the left [[coronary artery]]. If the [[myocardial infarction]] is treated with [[thrombolytic]] [[therapy]], the [[mortality]] increases to over 70%, mostly due to [[hemorrhage]] into the [[pericardial sac]] causing [[pericardial tamponade]]. Because [[aortic]] dissection may present to the [[emergency room]] [[physician]] similar to a [[myocardial infarction]], the physician must be careful to make the proper [[diagnosis]] prior to initiating treatment for [[myocardial infarction]], since the treatment regimen for [[myocardial infarction]] can be lethal to an individual presenting with [[aortic]] dissection.
The complications of aortic dissection include:<ref name="CambriaBrewster1988">{{cite journal|last1=Cambria|first1=Richard P.|last2=Brewster|first2=David C.|last3=Gertler|first3=Jonathan|last4=Moncure|first4=Ashby C.|last5=Gusberg|first5=Richard|last6=Tilson|first6=M.David|last7=Darling|first7=R.Clement|last8=Hammond|first8=Grahme|last9=Megerman|first9=Joseph|last10=Abbott|first10=William M.|title=Vascular complications associated with spontaneous aortic dissection|journal=Journal of Vascular Surgery|volume=7|issue=2|year=1988|pages=199–209|issn=07415214|doi=10.1016/0741-5214(88)90137-1}}</ref><ref name="FadahunsiRomeo2014">{{cite journal|last1=Fadahunsi|first1=Opeyemi|last2=Romeo|first2=Michael|title=Cardiac tamponade – presentation of type A aortic dissection|journal=Journal of Community Hospital Internal Medicine Perspectives|volume=4|issue=5|year=2014|pages=25449|issn=2000-9666|doi=10.3402/jchimp.v4.25449}}</ref><ref name="CaiCao2012">{{cite journal|last1=Cai|first1=Jingjing|last2=Cao|first2=Yu|last3=Yuan|first3=Hong|last4=Yang|first4=Kan|last5=Zhu|first5=Yuan-Shan|title=Inferior myocardial infarction secondary to aortic dissection associated with bicuspid aortic valve|journal=Journal of Cardiovascular Disease Research|volume=3|issue=2|year=2012|pages=138–142|issn=09753583|doi=10.4103/0975-3583.95370}}</ref><ref name="SiegelmanSprayregen1970">{{cite journal|last1=Siegelman|first1=Stanley S.|last2=Sprayregen|first2=Seymour|last3=Strasberg|first3=Zeno|last4=Attai|first4=Lari A.|last5=Robinson|first5=George|title=Aortic Dissection and the Left Renal Artery|journal=Radiology|volume=95|issue=1|year=1970|pages=73–78|issn=0033-8419|doi=10.1148/95.1.73}}</ref><ref name="BlancoDíez-Tejedor1999">{{cite journal|last1=Blanco|first1=M.|last2=Díez-Tejedor|first2=E.|last3=Larrea|first3=J. L.|last4=Ramírez|first4=U.|title=Neurologic complications of type I aortic dissection|journal=Acta Neurologica Scandinavica|volume=99|issue=4|year=1999|pages=232–235|issn=00016314|doi=10.1111/j.1600-0404.1999.tb07352.x}}</ref><ref name="ArataImagama2015">{{cite journal|last1=Arata|first1=Kenichi|last2=Imagama|first2=Itsumi|last3=Shigehisa|first3=Yoshiya|last4=Mukaihara|first4=Kousuke|last5=Toyokawa|first5=Kenji|last6=Matsuba|first6=Tomoyuki|last7=Imoto|first7=Yutaka|title=Aortic Fenestration for Type B Chronic Aortic Dissection Complicated with Lower Limb Malperfusion Induced by Walking Exercise|journal=Annals of Vascular Diseases|volume=8|issue=1|year=2015|pages=29–32|issn=1881-641X|doi=10.3400/avd.cr.14-00101}}</ref>
==== Cardiovascualr Complications====


====Thoracic Aortic Aneurysm====
*[[Aortic rupture]]
Redissection and [[aortic]] diameter enlargement as well as [[aneurysm]]al dilatation and [[saccular aneurysm]] [[chronic]]ally.
*[[Pericardial tamponade]]
*[[Acute aortic regurgitation]]
*[[Myocardial ischemia]]
*[[Thoracic aortic aneurysm]]
*[[Renal ischemia]]
*[[Superior mesenteric artery]] dissection and resultant [[visceral]] [[ischemia]]
*[[Pleural effusion]]
*[[Claudication]] due to an extension of the dissection into the [[iliac arteries]]


===Kidney===
======Neurologic Complications======
[[Renal ischemia]] due to dissection into the [[ostium]] of the [[renal]] [[vessel]]s can lead to [[hematuria]], [[renal infarction]], [[acute renal failure]]


===Mesentery===
*[[Ischemic]] [[cerebrovascular accident]] ([[CVA]]) due to dissection into the head [[vessel]]s
[[Visceral]] [[ischemia]] can occur due to extension of the dissection into the [[superior mesenteric artery]].
*[[Hemiplegia]] due to dissection into the [[spinal cord|spinal]] [[artery|arteries]]
*[[anesthesia|Hemianesthesia]] due to dissection into the [[spinal cord|spinal]] [[artery|arteries]]


===Lungs===
===== Compression of Nearby Organs=====
====Pleural effusion====
A [[pleural effusion]] (fluid collection in the space between the [[lung]]s and the chest wall or [[diaphragm (anatomy)|diaphragm]]) can be due to either blood from a transient rupture of the aorta or fluid due to an inflammatory reaction around the aorta. If a pleural effusion were to develop due to an aortic dissection, it is more commonly in the left hemithorax rather than the right hemithorax.
===Peripheral Arterial===
[[Claudication]] can occur due to an extension of the dissection into the iliac arteries.


===Neurologic===
*[[Superior vena cava syndrome]] due to compression of the [[superior vena cava]]
*Ischemic [[cerebrovascular accident]] ([[CVA]]) due to dissection into the head vessels
*[[Hemiplegia]] due to dissection into the spinal arteries
*[[Hemianesthesia]] due to dissection into the spinal arteries
 
=== Compression of Nearby Organs===
*Swelling of the neck and face (compression of the superior vena cava or [[Superior vena cava syndrome]])
*[[Horner syndrome]] (compression of the [[superior cervical ganglia]])
*[[Horner syndrome]] (compression of the [[superior cervical ganglia]])
*[[Dysphagia]] (compression of the [[esophagus]])
*[[Dysphagia]] due to (compression of the [[esophagus]])
*[[Stridor]] and [[wheezing]] (compression of the airway)
*[[Stridor]] and [[wheezing]] (compression of the airway)
*[[Hemoptysis]] (compression of and erosion into the [[bronchus]])
*[[Hemoptysis]] (compression of and erosion into the [[bronchus]])
*[[Vocal cord paralysis]] and [[hoarseness]] (compression of the [[recurrent laryngeal nerve]])
*[[Vocal cord paralysis]] and [[hoarseness]] (compression of the [[recurrent laryngeal nerve]])


==Prognosis==
===Prognosis===
The mortality rate is in large part determined by the patient's age and comorbidities.
 
===Pre-Operative and Immediate Post-Operative Prognosis===
*30% in hospital mortality
*60% 10-year survival rate among treated patients
 
Type A aortic dissection
*Surgical treatment-30% mortality rate
*Medical treatment-60% mortality rate
Type B aortic dissection
*Surgical treatment-10% mortality rate
*Medical treatment- 30% mortality rate


===Long Term Post-Operative Prognosis===
*Aortic dissection carries a poor [[prognosis]].<ref>{{cite journal|title=Correspondence|journal=The Annals of Thoracic Surgery|volume=67|issue=2|year=1999|pages=593|issn=00034975|doi=10.1016/S0003-4975(99)00037-5}}</ref>
The risk of death is highest in the first two years after the acute event, and individuals should be followed closely during this time period.  29% of late deaths following surgery are due to rupture of either the dissecting aneurysm or another aneurysm.  In additions, there is a 17 to 25% incidence of new aneurysm formation. This is typically due to dilatation of the residual false lumen.  These new aneurysms are more likely to rupture, due to their thinner walls.
*[[Mortality rate]] differs based on the type of dissection and is higher in type A compared to type B (25% versus 12%).


== References ==
== References ==
{{Reflist|2}}
{{Reflist|2}}
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Latest revision as of 15:54, 24 December 2019

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2] Sahar Memar Montazerin, M.D.[3]

Overview

The symptoms of aortic dissection usually develop in the fifth decade of life and start with symptoms such as sudden onset chest/back pain. If left untreated, patients with aortic dissection may progress to develop aortic regurgitation, myocardial ischemia, and cardiac tamponade. The complications of aortic dissection include but not limited to aortic rupture, pericardial tamponade, myocardial ischemia, compression of nearby organs and etc. Aortic dissection carries a poor prognosis. Mortality rate differs based on the type of dissection and is higher in type A compared to type B (25% versus 12%).

Natural History, Complications, and Prognosis

Natural History

Complications

The complications of aortic dissection include:[2][3][4][5][6][7]

Cardiovascualr Complications

Neurologic Complications
Compression of Nearby Organs

Prognosis

  • Aortic dissection carries a poor prognosis.[8]
  • Mortality rate differs based on the type of dissection and is higher in type A compared to type B (25% versus 12%).

References

  1. ↑ Juang, Derek; Braverman, Alan C.; Eagle, Kim (2008). "Aortic Dissection". Circulation. 118 (14). doi:10.1161/CIRCULATIONAHA.108.799908. ISSN 0009-7322.
  2. ↑ Cambria, Richard P.; Brewster, David C.; Gertler, Jonathan; Moncure, Ashby C.; Gusberg, Richard; Tilson, M.David; Darling, R.Clement; Hammond, Grahme; Megerman, Joseph; Abbott, William M. (1988). "Vascular complications associated with spontaneous aortic dissection". Journal of Vascular Surgery. 7 (2): 199–209. doi:10.1016/0741-5214(88)90137-1. ISSN 0741-5214.
  3. ↑ Fadahunsi, Opeyemi; Romeo, Michael (2014). "Cardiac tamponade – presentation of type A aortic dissection". Journal of Community Hospital Internal Medicine Perspectives. 4 (5): 25449. doi:10.3402/jchimp.v4.25449. ISSN 2000-9666.
  4. ↑ Cai, Jingjing; Cao, Yu; Yuan, Hong; Yang, Kan; Zhu, Yuan-Shan (2012). "Inferior myocardial infarction secondary to aortic dissection associated with bicuspid aortic valve". Journal of Cardiovascular Disease Research. 3 (2): 138–142. doi:10.4103/0975-3583.95370. ISSN 0975-3583.
  5. ↑ Siegelman, Stanley S.; Sprayregen, Seymour; Strasberg, Zeno; Attai, Lari A.; Robinson, George (1970). "Aortic Dissection and the Left Renal Artery". Radiology. 95 (1): 73–78. doi:10.1148/95.1.73. ISSN 0033-8419.
  6. ↑ Blanco, M.; Díez-Tejedor, E.; Larrea, J. L.; Ramírez, U. (1999). "Neurologic complications of type I aortic dissection". Acta Neurologica Scandinavica. 99 (4): 232–235. doi:10.1111/j.1600-0404.1999.tb07352.x. ISSN 0001-6314.
  7. ↑ Arata, Kenichi; Imagama, Itsumi; Shigehisa, Yoshiya; Mukaihara, Kousuke; Toyokawa, Kenji; Matsuba, Tomoyuki; Imoto, Yutaka (2015). "Aortic Fenestration for Type B Chronic Aortic Dissection Complicated with Lower Limb Malperfusion Induced by Walking Exercise". Annals of Vascular Diseases. 8 (1): 29–32. doi:10.3400/avd.cr.14-00101. ISSN 1881-641X.
  8. ↑ "Correspondence". The Annals of Thoracic Surgery. 67 (2): 593. 1999. doi:10.1016/S0003-4975(99)00037-5. ISSN 0003-4975.

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