Aortic dissection natural history, complications and prognosis

Aortic dissection Microchapters
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Case #1

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

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 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.

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:

• The aorta may rupture, leading to massive blood loss resulting in death. Indeed, aortic dissection accounts for 3-4% of sudden deaths.
• Hypotension and shock due to aortic rupture
• Pericardial tamponade
• Acute aortic regurgitationdue to the aortic dissection generating into Valsalva with an aortic valve insufficiency
• Pulmonary edema
• Myocardial ischemia or myocardial infarction due to involvement from the right or left coronary ostium (but most commonly the right coronary artery is involved
• Mesenteric and renal ischemia- can lead to hematuria, renal infarction, acute renal failure, or visceral ischemia
• Claudication due to an extension of the dissection into the iliac arteries
• Redissection and aortic diameter enlargement
• Aneurysmal dilatation and saccular aneurysm

Neurologic findings include:

• 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

Compressive symptoms include:

• Superior vena cava syndrome
• Horner syndrome (involves superior cervical ganglia)
• Dysphagia (involves the esophagus)
• Airway compromise
• Hemoptysis (involves the compression of the bronchus)
• Vocal cord paralysis and hoarseness

Prognosis

The mortality rate is in large part determined by the patient's age and comorbidities.

• 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