Aortic dissection diagnostic study of choice

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Case #1


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Sahar Memar Montazerin, M.D.[2] Aarti Narayan, M.B.B.S [3]

Overview

The diagnostic work-up of aortic dissection is highly dependent on the pretest probability of the patients as well as their hemodynamic status. In hemodynamically unstable patients, transesophageal echocardiography has the greatest value. CT scan, MRI, and transesophageal echocardiography have been observed to have similar reliability in the diagnosis of aortic dissection. However, CT and MRI have been preferred modality for assessing the extension and branch involvement in aortic dissection and diagnosing other types of acute aortic syndrome other than dissection as well as traumatic aortic lesions.

Diagnostic Study of Choice

The diagnostic work-up of aortic dissection is highly dependent on the pretest probability of the patients as well as their hemodynamic status.

Clinical Criteria

The table below provides clinical criteria to calculate the pretest probability of patients having an aortic dissection.[1]

Risk Stratification of Patients Suspicious for Aortic Dissection

High Risk Conditions Score
1
High Risk Pain Characteristics Score
  • Chest, back, or abdominal pain with at least one of the following features:
    • Abrupt onset
    • Severe intensity
    • Ripping or tearing
 1
High Risk Physical Findings Score
  • Evidence of insufficient blood supply:
    • Absent pulse
    • Systolic blood pressure difference
    • Focal neurological deficit (along with pain)
 1
  • Aortic diastolic murmur (new and with pain)

Comparison of Various Diagnostic Modalities for the Diagnosis of Aortic Dissection

Location Diagnostic Modality Diagnostic Value
Ascending Aortic Dissection
  • Moderate
  • Transesophageal echocardiography
  • Excellent
  • CT Scan
  • Excellent
  • MRI
  • Excellent
Aortic Arch Dissection
  • Transthoracic Echocardiography
  • Poor
  • Transoesophageal Echocardiography
  • Poor
  • CT Scan
  • Excellent
  • MRI
  • Excellent
Descending Aortic Dissection
  • Transthoracic Echocardiography
  • Poor
  • Transoesophageal Echocardiography
  • Excellent
  • CT Scan
  • Excellent
  • MRI
  • Excellent

2014 ESC Guidelines on the Diagnosis and Treatment of Aortic Diseases (DO NOT EDIT)[4]

Diagnostic Work-up of Patients Suspicious of Acute Aortic Syndrome

Class I
"Initial recommended imaging study for the diagnosis of acute aortic syndrome is transthoracic echocardiography. (Level of Evidence: C)"
"In case of initially negative imaging study, repetitive imaging study (including CT or MRI) is recommended if the suspicion for acute aortic syndrome is high. (Level of Evidence: C)"
"Repeated imaging study (including CT or MRI) is recommended in case of uncomplicated medially treated aortic dissection type B in the first few days of treatment. (Level of Evidence: C)"

Patients with Unstable Hemodynamic

Class I
"In patients with hemodynamic stability, transoesophageal echocardiography or computed tomography are the recommended imaging studies. preferred modality is chosen according to local availability or expertise. (Level of Evidence: C)"

Patients with Stable Hemodynamic[4]

Class I
"In stable patients, computed tomography or magnetic resonance imaging are the recommended imaging studies. prefered modality is chosen according to local availabilty or expertise. (Level of Evidence: C)"
Class IIa
"In stable patients, transoesophageal echocardiography is the recommended imaging study. (Level of Evidence: C)"

2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease (DO NOT EDIT)[1]

Screening Tests (DO NOT EDIT)[1]

Class I
"1. The role of chest x-ray in the evaluation of possible thoracic aortic disease should be directed by the patient's pretest risk of disease as follows:
a. Intermediate risk: Chest x-ray should be performed on all intermediate-risk patients, as it may establish a clear alternate diagnosis that will obviate the need for definitive aortic imaging. (Level of Evidence: C)
b. Low risk: Chest x-ray should be performed on all low-risk patients, as it may either establish an alternative diagnosis or demonstrate findings that are suggestive of thoracic aortic disease, indicating the need for urgent definitive aortic imaging. (Level of Evidence: C)"
"2. Urgent and definitive imaging of the aorta using transesophageal echocardiogram, computed tomographic imaging, or magnetic resonance imaging is recommended to identify or exclude thoracic aortic dissection in patients at high risk for the disease by initial screening.[5][6][7][2][8][9][10] (Level of Evidence: B)"
Class III (No Benefit)
"1. A negative chest x-ray should not delay definitive aortic imaging in patients determined to be high risk for aortic dissection by initial screening. (Level of Evidence: C)"

Aortic Imaging Techniques to Determine the Presence and Progression of Thoracic Aortic Disease (DO NOT EDIT)[1]

Class I
"1. Measurements of aortic diameter should be taken at reproducible anatomic landmarks, perpendicular to the axis of blood flow, and reported in a clear and consistent format. (Level of Evidence: C)"
"2. For measurements taken by computed tomographic imaging or magnetic resonance imaging, the external diameter should be measured perpendicular to the axis of blood flow. For aortic root measurements, the widest diameter, typically at the mid-sinus level, should be used. (Level of Evidence: C)"
"3. For measurements taken by echocardiography, the internal diameter should be measured perpendicular to the axis of blood flow. For aortic root measurements the widest diameter, typically at the mid-sinus level, should be used. (Level of Evidence: C)"
"4. Abnormalities of aortic morphology should be recognized and reported separately even when aortic diameters are within normal limits. (Level of Evidence: C)"
"5. The finding of aortic dissection, aneurysm, traumatic injury and/or aortic rupture should be immediately communicated to the referring physician. (Level of Evidence: C)"
"6. Techniques to minimize episodic and cumulative radiation exposure should be utilized whenever possible.[11][12] (Level of Evidence: B)"
Class IIa
"1. If clinical information is available, it can be useful to relate aortic diameter to the patient's age and body size. (Level of Evidence: C)"

Genetic Syndromes (DO NOT EDIT)[1]

Class I
"1. An echocardiogram is recommended at the time of diagnosis of Marfan syndrome to determine the aortic root and ascending aortic diameters and 6 months thereafter to determine the rate of enlargement of the aorta. (Level of Evidence: C)"
"2. Annual imaging is recommended for patients with Marfan syndrome if stability of the aortic diameter is documented. If the maximal aortic diameter is 4.5 cm or greater, or if the aortic diameter shows significant growth from baseline, more frequent imaging should be considered. (Level of Evidence: C)"
"3. Patients with Loeys-Dietz syndrome or a confirmed genetic mutation known to predispose to aortic aneurysms and aortic dissections (TGFBR1, TGFBR2, FBN1, ACTA2, or MYH11) should undergo complete aortic imaging at initial diagnosis and 6 months thereafter to establish if enlargement is occurring.[13][14][15][16] (Level of Evidence: C)"
"4. Patients with Loeys-Dietz syndrome should have yearly magnetic resonance imaging from the cerebrovascular circulation to the pelvis.[17][18][19] (Level of Evidence: B)"
"5. Patients with Turner syndrome should undergo imaging of the heart and aorta for evidence of bicuspid aortic valve, coarctation of the aorta, or dilatation of the ascending thoracic aorta.[20] If initial imaging is normal and there are no risk factors for aortic dissection, repeat imaging should be performed every 5 to 10 years or if otherwise clinically indicated. If abnormalities exist, annual imaging or follow-up imaging should be done. (Level of Evidence: C)"
Class IIa
"1. It is reasonable to consider surgical repair of the aorta in all adult patients with Loeys-Dietz syndrome or a confirmed TGFBR1 or TGFBR2 mutation and an aortic diameter of 4.2 cm or greater by transesophageal echocardiogram (internal diameter) or 4.4 to 4.6 cm or greater by computed tomographic imaging and/or magnetic resonance imaging (external diameter).[18] (Level of Evidence: C)"
"2. For women with Marfan syndrome contemplating pregnancy, it is reasonable to prophylactically replace the aortic root and ascending aorta if the diameter exceeds 4.0 cm.[13] (Level of Evidence: C)"
"3. If the maximal cross-sectional area in square centimeters of the ascending aorta or root divided by the patient's height in meters exceeds a ratio of 10, surgical repair is reasonable because shorter patients have dissection at a smaller size and 15% of patients with Marfan syndrome have dissection at a size smaller than 5.0 cm.[15][21][22] (Level of Evidence: C)"
Class IIb
"1. In patients with Turner syndrome with additional risk factors, including bicuspid aortic valve, coarctation of the aorta, and/or hypertension, and in patients who attempt to become pregnant or who become pregnant, it may be reasonable to perform imaging of the heart and aorta to help determine the risk of aortic dissection. (Level of Evidence: C)"

Familial Thoracic Aortic Aneurysms and Dissections (DO NOT EDIT)[1]

Class I
"1. Aortic imaging is recommended for first-degree relatives of patients with thoracic aortic aneurysm and/or dissection to identify those with asymptomatic disease.[23][24] (Level of Evidence: B)"
"2. If the mutant gene (FBN1, TGFBR1, TGFBR2, COL3A1, ACTA2, MYH11) associated with aortic aneurysm and/or dissection is identified in a patient, first-degree relatives should undergo counseling and testing. Then, only the relatives with the genetic mutation should undergo aortic imaging. (Level of Evidence: C)"
Class IIa
"1. If one or more first-degree relatives of a patient with known thoracic aortic aneurysm and/or dissection are found to have thoracic aortic dilatation, aneurysm, or dissection, then imaging of second-degree relatives is reasonable.[23] (Level of Evidence: B)"

Takayasu Arteritis and Giant Cell Arteritis (DO NOT EDIT)[1]

Class I
"1. The initial evaluation of Takayasu arteritis or giant cell arteritis should include thoracic aorta and branch vessel computed tomographic imaging or magnetic resonance imaging to investigate the possibility of aneurysm or occlusive disease in these vessels. (Level of Evidence: C)"

Diagnostic Imaging Studies (DO NOT EDIT)[1]

Class I
"1. Selection of a specific imaging modality to identify or exclude aortic dissection should be based on patient variables and institutional capabilities, including immediate availability. (Level of Evidence: C)"
"2. If a high clinical suspicion exists for acute aortic dissection but initial aortic imaging is negative, a second imaging study should be obtained.[25] (Level of Evidence: C)"

Bicuspid Aortic Valve and Associated Congenital Variants in Adults (DO NOT EDIT)[1]

Class I
"1. First-degree relatives of patients with a bicuspid aortic valve, premature onset of thoracic aortic disease with minimal risk factors, and/or a familial form of thoracic aortic aneurysm and dissection should be evaluated for the presence of a bicuspid aortic valve and asymptomatic thoracic aortic disease. (Level of Evidence: C)"
"2. All patients with a bicuspid aortic valve should have both the aortic root and ascending thoracic aorta evaluated for evidence of aortic dilatation.[26][27][28][29] (Level of Evidence: B)"

Surveillance of Thoracic Aortic Disease or Previously Repaired Patients (DO NOT EDIT)[1]

Class IIa
"1. Computed tomographic imaging or magnetic resonance imaging of the thoracic aorta is reasonable after a Type A or B aortic dissection or after prophylactic repair of the aortic root/ ascending aorta.[13] (Level of Evidence: C)"
"2. Computed tomographic imaging or magnetic resonance imaging of the aorta is reasonable at 1, 3, 6, and 12 months postdissection and, if stable, annually thereafter so that any threatening enlargement can be detected in a timely fashion. (Level of Evidence: C)"
"3. When following patients with imaging, utilization of the same modality at the same institution is reasonable, so that similar images of matching anatomic segments can be compared side by side. (Level of Evidence: C)"
"4. If a thoracic aortic aneurysm is only moderate in size and remains relatively stable over time, magnetic resonance imaging instead of computed tomographic imaging is reasonable to minimize the patient’s radiation exposure. (Level of Evidence: C)"
"5. Surveillance imaging similar to classic aortic dissection is reasonable in patients with intramural hematoma. (Level of Evidence: C)"

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 Hiratzka LF, Bakris GL, Beckman JA; et al. (2010). "2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine". Circulation. 121 (13): e266–369. doi:10.1161/CIR.0b013e3181d4739e. PMID 20233780. Unknown parameter |month= ignored (help)
  2. ↑ 2.0 2.1 Shiga T, Wajima Z, Apfel CC, Inoue T, Ohe Y (July 2006). "Diagnostic accuracy of transesophageal echocardiography, helical computed tomography, and magnetic resonance imaging for suspected thoracic aortic dissection: systematic review and meta-analysis". Arch. Intern. Med. 166 (13): 1350–6. doi:10.1001/archinte.166.13.1350. PMID 16831999.
  3. ↑ Quint LE, Francis IR, Williams DM, Bass JC, Shea MJ, Frayer DL, Monaghan HM, Deeb GM (October 1996). "Evaluation of thoracic aortic disease with the use of helical CT and multiplanar reconstructions: comparison with surgical findings". Radiology. 201 (1): 37–41. doi:10.1148/radiology.201.1.8816517. PMID 8816517.
  4. ↑ 4.0 4.1 4.2 Erbel R, Aboyans V, Boileau C, Bossone E, Bartolomeo RD, Eggebrecht H, Evangelista A, Falk V, Frank H, Gaemperli O, Grabenwöger M, Haverich A, Iung B, Manolis AJ, Meijboom F, Nienaber CA, Roffi M, Rousseau H, Sechtem U, Sirnes PA, Allmen RS, Vrints CJ (November 2014). "2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC)". Eur. Heart J. 35 (41): 2873–926. doi:10.1093/eurheartj/ehu281. PMID 25173340.
  5. ↑ Yoshida S, Akiba H, Tamakawa M; et al. (2003). "Thoracic involvement of type A aortic dissection and intramural hematoma: diagnostic accuracy--comparison of emergency helical CT and surgical findings". Radiology. 228 (2): 430–5. doi:10.1148/radiol.2282012162. PMID 12819341. Unknown parameter |month= ignored (help)
  6. ↑ Sommer T, Fehske W, Holzknecht N; et al. (1996). "Aortic dissection: a comparative study of diagnosis with spiral CT, multiplanar transesophageal echocardiography, and MR imaging". Radiology. 199 (2): 347–52. PMID 8668776. Unknown parameter |month= ignored (help)
  7. ↑ Zeman RK, Berman PM, Silverman PM; et al. (1995). "Diagnosis of aortic dissection: value of helical CT with multiplanar reformation and three-dimensional rendering". AJR Am J Roentgenol. 164 (6): 1375–80. PMID 7754876. Unknown parameter |month= ignored (help)
  8. ↑ Nienaber CA, von Kodolitsch Y, Nicolas V; et al. (1993). "The diagnosis of thoracic aortic dissection by noninvasive imaging procedures". N. Engl. J. Med. 328 (1): 1–9. doi:10.1056/NEJM199301073280101. PMID 8416265. Unknown parameter |month= ignored (help)
  9. ↑ Erbel R, Engberding R, Daniel W, Roelandt J, Visser C, Rennollet H (1989). "Echocardiography in diagnosis of aortic dissection". Lancet. 1 (8636): 457–61. PMID 2563839. Unknown parameter |month= ignored (help)
  10. ↑ Börner N, Erbel R, Braun B, Henkel B, Meyer J, Rumpelt J (1984). "Diagnosis of aortic dissection by transesophageal echocardiography". Am. J. Cardiol. 54 (8): 1157–8. PMID 6496346. Unknown parameter |month= ignored (help)
  11. ↑ Amis ES, Butler PF, Applegate KE; et al. (2007). "American College of Radiology white paper on radiation dose in medicine". J Am Coll Radiol. 4 (5): 272–84. doi:10.1016/j.jacr.2007.03.002. PMID 17467608. Unknown parameter |month= ignored (help)
  12. ↑ Brenner DJ, Hall EJ (2007). "Computed tomography--an increasing source of radiation exposure". N. Engl. J. Med. 357 (22): 2277–84. doi:10.1056/NEJMra072149. PMID 18046031. Unknown parameter |month= ignored (help)
  13. ↑ 13.0 13.1 13.2 Pearson GD, Devereux R, Loeys B; et al. (2008). "Report of the National Heart, Lung, and Blood Institute and National Marfan Foundation Working Group on research in Marfan syndrome and related disorders". Circulation. 118 (7): 785–91. doi:10.1161/CIRCULATIONAHA.108.783753. PMC 2909440. PMID 18695204. Unknown parameter |month= ignored (help)
  14. ↑ Svensson LG, Crawford ES, Coselli JS, Safi HJ, Hess KR (1989). "Impact of cardiovascular operation on survival in the Marfan patient". Circulation. 80 (3 Pt 1): I233–42. PMID 2766531. Unknown parameter |month= ignored (help)
  15. ↑ 15.0 15.1 Svensson LG, Blackstone EH, Feng J; et al. (2007). "Are Marfan syndrome and marfanoid patients distinguishable on long-term follow-up?". Ann. Thorac. Surg. 83 (3): 1067–74. doi:10.1016/j.athoracsur.2006.10.062. PMID 17307461. Unknown parameter |month= ignored (help)
  16. ↑ Zhu L, Vranckx R, Khau Van Kien P; et al. (2006). "Mutations in myosin heavy chain 11 cause a syndrome associating thoracic aortic aneurysm/aortic dissection and patent ductus arteriosus". Nat. Genet. 38 (3): 343–9. doi:10.1038/ng1721. PMID 16444274. Unknown parameter |month= ignored (help)
  17. ↑ LeMaire SA, Pannu H, Tran-Fadulu V, Carter SA, Coselli JS, Milewicz DM (2007). "Severe aortic and arterial aneurysms associated with a TGFBR2 mutation". Nat Clin Pract Cardiovasc Med. 4 (3): 167–71. doi:10.1038/ncpcardio0797. PMC 2561071. PMID 17330129. Unknown parameter |month= ignored (help)
  18. ↑ 18.0 18.1 Loeys BL, Schwarze U, Holm T; et al. (2006). "Aneurysm syndromes caused by mutations in the TGF-beta receptor". N. Engl. J. Med. 355 (8): 788–98. doi:10.1056/NEJMoa055695. PMID 16928994. Unknown parameter |month= ignored (help)
  19. ↑ Williams JA, Loeys BL, Nwakanma LU; et al. (2007). "Early surgical experience with Loeys-Dietz: a new syndrome of aggressive thoracic aortic aneurysm disease". Ann. Thorac. Surg. 83 (2): S757–63, discussion S785–90. doi:10.1016/j.athoracsur.2006.10.091. PMID 17257922. Unknown parameter |month= ignored (help)
  20. ↑ Bondy CA, Turner Syndrome Study Group (2007). "Care of girls and women with Turner syndrome: a guideline of the Turner Syndrome Study Group". J Clin Endocrinol Metab. 92 (1): 10–25. doi:10.1210/jc.2006-1374. PMID 17047017.
  21. ↑ Gott VL, Greene PS, Alejo DE; et al. (1999). "Replacement of the aortic root in patients with Marfan's syndrome". N. Engl. J. Med. 340 (17): 1307–13. doi:10.1056/NEJM199904293401702. PMID 10219065. Unknown parameter |month= ignored (help)
  22. ↑ Svensson LG, Khitin L (2002). "Aortic cross-sectional area/height ratio timing of aortic surgery in asymptomatic patients with Marfan syndrome". J. Thorac. Cardiovasc. Surg. 123 (2): 360–1. PMID 11828302. Unknown parameter |month= ignored (help)
  23. ↑ 23.0 23.1 Albornoz G, Coady MA, Roberts M; et al. (2006). "Familial thoracic aortic aneurysms and dissections--incidence, modes of inheritance, and phenotypic patterns". Ann. Thorac. Surg. 82 (4): 1400–5. doi:10.1016/j.athoracsur.2006.04.098. PMID 16996941. Unknown parameter |month= ignored (help)
  24. ↑ Coady MA, Davies RR, Roberts M; et al. (1999). "Familial patterns of thoracic aortic aneurysms". Arch Surg. 134 (4): 361–7. PMID 10199307. Unknown parameter |month= ignored (help)
  25. ↑ Svensson LG, Labib SB, Eisenhauer AC, Butterly JR (1999). "Intimal tear without hematoma: an important variant of aortic dissection that can elude current imaging techniques". Circulation. 99 (10): 1331–6. PMID 10077517. Unknown parameter |month= ignored (help)
  26. ↑ Braverman AC, Güven H, Beardslee MA, Makan M, Kates AM, Moon MR (2005). "The bicuspid aortic valve". Curr Probl Cardiol. 30 (9): 470–522. doi:10.1016/j.cpcardiol.2005.06.002. PMID 16129122. Unknown parameter |month= ignored (help)
  27. ↑ Borger MA, David TE (2005). "Management of the valve and ascending aorta in adults with bicuspid aortic valve disease". Semin. Thorac. Cardiovasc. Surg. 17 (2): 143–7. doi:10.1053/j.semtcvs.2005.02.005. PMID 16087084.
  28. ↑ Svensson LG, Blackstone EH, Cosgrove DM (2003). "Surgical options in young adults with aortic valve disease". Curr Probl Cardiol. 28 (7): 417–80. doi:10.1016/j.cpcardiol.2003.08.002. PMID 14647130. Unknown parameter |month= ignored (help)
  29. ↑ Svensson LG (2008). "Aortic valve stenosis and regurgitation: an overview of management". J Cardiovasc Surg (Torino). 49 (2): 297–303. PMID 18431353. Unknown parameter |month= ignored (help)
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