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{{Template:Aortic dissection}}
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{{CMG}}; '''Associate Editor-In-Chief:''' {{CZ}}
{{CMG}}; '''Associate Editor-In-Chief:''' {{CZ}} {{Sahar}}


==Overview==
==Overview==
[[Aortic dissection]] is commonly associated with varying blood pressure (pseudohypotension or [[hypertension]] or [[hypotension]]), [[wide pulse pressure]] (if the [[aortic root]] is involved causing [[aortic insufficiency]]), [[tachycardia]], [[pulsus paradoxus]], [[swollen face]] due to [[superior vena cava]] compression ([[superior vena cava syndrome]]). In proximal dissections involving [[aortic root]], [[aortic insufficiency]] is a [[complication]], and on physical examination an early [[diastolic]] decrescendo [[murmur]], which is best heard in the right second [[intercostal space]] is noted.
[[Aortic dissection]] is commonly associated with varying blood pressure (pseudohypotension or [[hypertension]] or [[hypotension]]), [[wide pulse pressure]] (if the [[aortic root]] is involved causing [[aortic insufficiency]]), [[tachycardia]], [[pulsus paradoxus]], [[swollen face]] due to [[superior vena cava]] compression ([[superior vena cava syndrome]]). In proximal dissections involving [[aortic root]], [[aortic insufficiency]] is a [[complication]], and on physical examination an early [[diastolic]] decrescendo [[murmur]], which is best heard in the right second [[intercostal space]] is noted.
==Vitals==
==Physical Examination==
===Blood Pressure===
===Vitals===
====Blood Pressure Discrepancy====
====Pulse====
=====Rate=====
*[[Tachycardia]] may be present due to [[pain]], [[anxiety]], [[aortic rupture]] with [[massive bleeding]], [[pericardial tamponade]], [[aortic insufficiency]] with [[acute]] [[pulmonary edema]] and [[hypoxemia]].
=====Strength=====
* [[Pulsus paradoxus]] (a drop of > 10 mmHg in [[artery|arterial]] [[blood pressure]] on [[inspiration]]) may be present of [[pericardial tamponade]] develops.
====Blood Pressure====
''Pseudohypotension'' (falsely low [[blood pressure]] measurement) may occur due to involvement of the [[brachiocephalic artery]] (supplying the right arm) or the [[left subclavian artery]] (supplying the left arm).
''Pseudohypotension'' (falsely low [[blood pressure]] measurement) may occur due to involvement of the [[brachiocephalic artery]] (supplying the right arm) or the [[left subclavian artery]] (supplying the left arm).
==== Hypertension====
While many patients with an [[aortic]] dissection have a history of [[arterial hypertension|hypertension]], the [[blood pressure]] is quite variable among patients with [[acute]] [[aortic]] dissection, and tends to be higher in individuals with a [[distal]] dissection. In individuals with a [[proximal]] [[aortic]] dissection, 36% present with [[arterial hypertension|hypertension]], while 25% present with [[hypotension]]. In those that present with [[distal]] [[aortic]] dissections, 70% present with [[hypertension]] while 4% present with [[hypotension]].
==== Hypotension====
Severe [[hypotension]] at presentation is a grave [[prognosis|prognostic]] indicator. It is usually associated with [[pericardial tamponade]], severe [[aortic insufficiency]], or [[rupture of the aorta]]. Accurate measurement of the [[blood pressure]] is important.


===Pulse===
While many patients with an [[aortic]] dissection have a history of [[arterial hypertension|hypertension]], the [[blood pressure]] is quite variable among patients with [[acute]] [[aortic]] dissection, and tends to be higher in individuals with a [[distal]] dissection. In individuals with a [[proximal]] [[aortic]] dissection, 36% present with [[arterial hypertension|hypertension]], while 25% present with [[hypotension]]. In those that present with [[distal]] [[aortic]] dissections, 70% present with [[hypertension]] while 4% present with [[hypotension]]. A [[wide pulse pressure]] may be present if [[acute]] [[aortic insufficiency]] develops.
*[[Tachycardia]] may be present due to [[pain]], [[anxiety]], [[aortic rupture]] with [[massive bleeding]], [[pericardial tamponade]], [[aortic insufficiency]] with [[acute]] [[pulmonary edema]] and [[hypoxemia]].
*A [[wide pulse pressure]] may be present if [[acute]] [[aortic insufficiency]] develops.
* [[Pulsus paradoxus]] (a drop of > 10 mmHg in [[artery|arterial]] [[blood pressure]] on [[inspiration]]) may be present of [[pericardial tamponade]] develops.


==General==
Severe [[hypotension]] at presentation is a grave [[prognosis|prognostic]] indicator. It is usually associated with [[pericardial tamponade]], severe [[aortic insufficiency]], or [[rupture of the aorta]]. Accurate measurement of the [[blood pressure]] is important.
The patient may be [[hoarse]] due to compression of the left [[recurrent laryngeal nerve]].


==Head, Eyes, Ears, Nose, Throat==
===HEENT===
*[[Swelling]] of the neck and face may be present due to compression of the [[superior vena cava]] or [[Superior vena cava syndrome]]
*[[Swelling]] of the neck and face may be present due to compression of the [[superior vena cava]] or [[Superior vena cava syndrome]]
*[[Horner syndrome]] may be present due to compression of the [[superior cervical ganglia]]
*[[Horner syndrome]] may be present due to compression of the [[superior cervical ganglia]]
*The patient may be [[hoarse]] due to compression of the left [[recurrent laryngeal nerve]].


== Heart ==
=== Lungs ===
===Aortic Insufficiency===
*[[Rales]] may be present due to [[cardiogenic pulmonary edema]] which may result from [[acute]] [[aortic regurgitation]].
*[[Hemothorax]] and / or [[pleural effusion]] may cause dullness to [[percussion]].
*[[Stridor]] and [[wheezing]] may be present due to compression of the airway
*[[Hemoptysis]] may be present due to compression of and erosion into the [[bronchus]]
=== Heart ===
====Aortic Insufficiency====
[[Aortic insufficiency]] 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]]. [[Aortic insufficiency]] is more commonly associated with type I or type II dissection. The [[murmur]] of [[aortic insufficiency]] ([[AI]]) due to [[aortic]] dissection is best heard at the right 2nd [[intercostal space]] (ICS), as compared with the lower left [[sternal]] border for [[AI]] due to primary [[aortic]] [[valvular disease]].
[[Aortic insufficiency]] 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]]. [[Aortic insufficiency]] is more commonly associated with type I or type II dissection. The [[murmur]] of [[aortic insufficiency]] ([[AI]]) due to [[aortic]] dissection is best heard at the right 2nd [[intercostal space]] (ICS), as compared with the lower left [[sternal]] border for [[AI]] due to primary [[aortic]] [[valvular disease]].
 
====Cardiac Tamponade====
===Cardiac Tamponade===
* [[Beck's triad]] may be present:<ref>Gwinnutt, C., Driscoll, P. (Eds) (2003) (2nd Ed.) Trauma Resuscitation: The Team Approach. Oxford: BIOS Scientific Publishers Ltd. ISBN 978-1859960097 </ref>
* [[Beck's triad]] may be present:<ref>Gwinnutt, C., Driscoll, P. (Eds) (2003) (2nd Ed.) Trauma Resuscitation: The Team Approach. Oxford: BIOS Scientific Publishers Ltd. ISBN 978-1859960097 </ref>
** [[Hypotension]] (due to decreased [[stroke volume]])
** [[Hypotension]] (due to decreased [[stroke volume]])
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* Clicks - As [[ventricular]] volume shrinks disproportionately, there may be psuedoprolapse/true prolapse of [[mitral]] and/or [[tricuspid valve|tricuspid valvular]] structures that result in clicks.
* Clicks - As [[ventricular]] volume shrinks disproportionately, there may be psuedoprolapse/true prolapse of [[mitral]] and/or [[tricuspid valve|tricuspid valvular]] structures that result in clicks.
* [[Kussmaul's sign]] - Decrease in [[jugular venous pressure]] with [[inspiration]] is uncommon.
* [[Kussmaul's sign]] - Decrease in [[jugular venous pressure]] with [[inspiration]] is uncommon.
 
=== Extremities ===
== Lungs ==
Diminution or absence of [[pulse]]s is found in up to 40% of patients, and occurs due to occlusion of a major [[aortic]] branch. For this reason it is critical to assess the [[pulse]] and [[blood pressure]] in both arms.  The [[iliac arteries]] may be affected as well.
*[[Rales]] may be present due to [[cardiogenic pulmonary edema]] which may result from [[acute]] [[aortic regurgitation]].
=== Neurologic ===
*[[Hemothorax]] and / or [[pleural effusion]] may cause dullness to [[percussion]].
* [[Neurologic]] deficits such as [[coma]], [[altered mental status]], [[Ddx:Cerebrovascular Accident|Cerebrovascular accident]] (CVA) and [[vagal episodes]] are seen in up to 20%.
*[[Stridor]] and [[wheezing]] may be present due to compression of the airway
*There can also be focal [[neurologic]] signs due to occlusion of a [[Anterior spinal artery|spinal artery]]. This condition is known as [[Anterior spinal artery syndrome]] or [[Anterior spinal artery syndrome|"Beck's syndrome"]].
*[[Hemoptysis]] may be present due to compression of and erosion into the [[bronchus]]
===Physical Examination Findings associated with High Pretest Probability of Aortic Dissection (DO NOT EDIT)<ref name="pmid25173340">{{cite journal |vauthors=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 |title=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) |journal=Eur. Heart J. |volume=35 |issue=41 |pages=2873–926 |date=November 2014 |pmid=25173340 |doi=10.1093/eurheartj/ehu281 |url=}}</ref>===
 
{|class="wikitable"
== Extremities ==
|-
Diminution or absence of pulses is found in up to 40% of patients, and occurs due to occlusion of a major aortic branch. For this reason it is critical to assess the pulse and blood pressure in both arms.  The iliac arteries may be affected as well.
| colspan="1" style="text-align:center; background:Blue"|[[ESC guidelines classification scheme#Classification of Recommendations|Physical Examination Findings]]
 
|-
== Neurologic ==
|bgcolor="LightBlue" |
* Neurologic deficits such as [[coma]], altered mental status, [[Ddx:Cerebrovascular Accident|Cerebrovascular accident]] (CVA) and [[vagal episodes]] are seen in up to 20%.
* Evidence of insufficient blood supply:
*There can also be focal neurologic signs due to occlusion of a [[Anterior spinal artery|spinal artery]]. This condition is known as [[Anterior spinal artery syndrome]] or [[Anterior spinal artery syndrome|"Beck's syndrome"]].
** Absent pulse
** Systolic blood pressure difference
** Focal neurological deficit (along with pain)
* Aortic diastolic murmur (new and with pain)
* Hypotension or shock
|}
==2014 ESC Guidelines on the Diagnosis and Treatment of Aortic Diseases (DO NOT EDIT)<ref name="pmid25173340">{{cite journal |vauthors=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 |title=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) |journal=Eur. Heart J. |volume=35 |issue=41 |pages=2873–926 |date=November 2014 |pmid=25173340 |doi=10.1093/eurheartj/ehu281 |url=}}</ref>==
===Clinical Assessment of Patients Suspicious of Aortic Dissection (DO NOT EDIT)<ref name="pmid25173340">{{cite journal |vauthors=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 |title=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) |journal=Eur. Heart J. |volume=35 |issue=41 |pages=2873–926 |date=November 2014 |pmid=25173340 |doi=10.1093/eurheartj/ehu281 |url=}}</ref>===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ESC guidelines classification scheme#Classification of Recommendations|Class I]]
|-
|bgcolor="LightGreen" |<nowiki>"</nowiki>In all patients with suspected AAS, pre-test probability assessment is recommended, according to the patient’s condition, symptoms, and clinical features.<ref name="EvangelistaIsselbacher2018">{{cite journal|last1=Evangelista|first1=Arturo|last2=Isselbacher|first2=Eric M.|last3=Bossone|first3=Eduardo|last4=Gleason|first4=Thomas G.|last5=Eusanio|first5=Marco Di|last6=Sechtem|first6=Udo|last7=Ehrlich|first7=Marek P.|last8=Trimarchi|first8=Santi|last9=Braverman|first9=Alan C.|last10=Myrmel|first10=Truls|last11=Harris|first11=Kevin M.|last12=Hutchinson|first12=Stuart|last13=O’Gara|first13=Patrick|last14=Suzuki|first14=Toru|last15=Nienaber|first15=Christoph A.|last16=Eagle|first16=Kim A.|title=Insights From the International Registry of Acute Aortic Dissection|journal=Circulation|volume=137|issue=17|year=2018|pages=1846–1860|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.117.031264}}</ref>''([[ESC guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}


==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) <ref name="pmid20233780">{{cite journal| author=Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE et al.| title=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. | journal=Circulation | year= 2010 | volume= 121 | issue= 13 | pages= e266-369 | pmid=20233780 | doi=10.1161/CIR.0b013e3181d4739e | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20233780  }} </ref>==
==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) <ref name="pmid20233780">{{cite journal| author=Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE et al.| title=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. | journal=Circulation | year= 2010 | volume= 121 | issue= 13 | pages= e266-369 | pmid=20233780 | doi=10.1161/CIR.0b013e3181d4739e | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20233780  }} </ref>==
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| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
|-
|bgcolor="LightGreen" |<nowiki>"</nowiki>'''1.''' For patients presenting with a history of acute cardiac and noncardiac symptoms associated with a significant likelihood of thoracic aortic disease, the clinician should perform a focused physical examination, including a careful and complete search for arterial perfusion differentials in both upper and lower extremities, evidence of visceral [[ischemia]], focal neurological deficits, a [[murmur]] of [[aortic regurgitation]], [[bruit]]s, and findings compatible with possible [[cardiac tamponade]].<ref>Townsend CM, Beauchamp RD, Evers BM, et al. Sabiston Textbook of Surgery. 18th ed. Philadelphia: Elsevier Health Sciences, 2008.</ref><ref>Libby P, Bonow RO, Mann DL, et al. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. 8th ed. Philadelphia: 2007.</ref><ref>Isselbacher E. Cecil Medicine. 23rd ed. Philadelphia: Elsevier Health Sciences, 2008.</ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>  
|bgcolor="LightGreen" |<nowiki>"</nowiki>'''1.''' For patients presenting with a history of [[acute]] [[cardiac]] and non [[cardiac]] [[symptom]]s associated with a significant likelihood of [[thoracic aorta|thoracic aortic]] disease, the clinician should perform a focused physical examination, including a careful and complete search for [[artery|arterial]] [[perfusion]] differentials in both upper and lower extremities, evidence of [[visceral]] [[ischemia]], focal [[neurological]] deficits, a [[murmur]] of [[aortic regurgitation]], [[bruit]]s, and findings compatible with possible [[cardiac tamponade]].<ref>Townsend CM, Beauchamp RD, Evers BM, et al. Sabiston Textbook of Surgery. 18th ed. Philadelphia: Elsevier Health Sciences, 2008.</ref><ref>Libby P, Bonow RO, Mann DL, et al. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. 8th ed. Philadelphia: 2007.</ref><ref>Isselbacher E. Cecil Medicine. 23rd ed. Philadelphia: Elsevier Health Sciences, 2008.</ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>  
|}
|}


== References ==
== References ==
{{Reflist|2}}
{{Reflist|2}}
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[[Category:Cardiology]]
[[Category:Cardiology]]
[[Category:Emergency medicine]]
[[Category:Emergency medicine]]
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[[Category:Up-To-Date]]
[[Category:Up-To-Date]]
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Latest revision as of 21:09, 18 December 2019

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] Sahar Memar Montazerin, M.D.[3]

Overview

Aortic dissection is commonly associated with varying blood pressure (pseudohypotension or hypertension or hypotension), wide pulse pressure (if the aortic root is involved causing aortic insufficiency), tachycardia, pulsus paradoxus, swollen face due to superior vena cava compression (superior vena cava syndrome). In proximal dissections involving aortic root, aortic insufficiency is a complication, and on physical examination an early diastolic decrescendo murmur, which is best heard in the right second intercostal space is noted.

Physical Examination

Vitals

Pulse

Rate
Strength

Blood Pressure

Pseudohypotension (falsely low blood pressure measurement) may occur due to involvement of the brachiocephalic artery (supplying the right arm) or the left subclavian artery (supplying the left arm).

While many patients with an aortic dissection have a history of hypertension, the blood pressure is quite variable among patients with acute aortic dissection, and tends to be higher in individuals with a distal dissection. In individuals with a proximal aortic dissection, 36% present with hypertension, while 25% present with hypotension. In those that present with distal aortic dissections, 70% present with hypertension while 4% present with hypotension. A wide pulse pressure may be present if acute aortic insufficiency develops.

Severe hypotension at presentation is a grave prognostic indicator. It is usually associated with pericardial tamponade, severe aortic insufficiency, or rupture of the aorta. Accurate measurement of the blood pressure is important.

HEENT

Lungs

Heart

Aortic Insufficiency

Aortic insufficiency occurs in 1/2 to 2/3 of ascending aortic dissections, and the 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. Aortic insufficiency is more commonly associated with type I or type II dissection. The murmur of aortic insufficiency (AI) due to aortic dissection is best heard at the right 2nd intercostal space (ICS), as compared with the lower left sternal border for AI due to primary aortic valvular disease.

Cardiac Tamponade

In addition to the Beck's triad and pulsus paradoxus the following can be found on cardiovascular examination:

Extremities

Diminution or absence of pulses is found in up to 40% of patients, and occurs due to occlusion of a major aortic branch. For this reason it is critical to assess the pulse and blood pressure in both arms. The iliac arteries may be affected as well.

Neurologic

Physical Examination Findings associated with High Pretest Probability of Aortic Dissection (DO NOT EDIT)[3]

Physical Examination Findings
  • Evidence of insufficient blood supply:
    • Absent pulse
    • Systolic blood pressure difference
    • Focal neurological deficit (along with pain)
  • Aortic diastolic murmur (new and with pain)
  • Hypotension or shock

2014 ESC Guidelines on the Diagnosis and Treatment of Aortic Diseases (DO NOT EDIT)[3]

Clinical Assessment of Patients Suspicious of Aortic Dissection (DO NOT EDIT)[3]

Class I
"In all patients with suspected AAS, pre-test probability assessment is recommended, according to the patient’s condition, symptoms, and clinical features.[4](Level of Evidence: B)"

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) [5]

History and Physical Examination for Thoracic Aortic Disease (DO NOT EDIT)[5]

Class I
"1. For patients presenting with a history of acute cardiac and non cardiac symptoms associated with a significant likelihood of thoracic aortic disease, the clinician should perform a focused physical examination, including a careful and complete search for arterial perfusion differentials in both upper and lower extremities, evidence of visceral ischemia, focal neurological deficits, a murmur of aortic regurgitation, bruits, and findings compatible with possible cardiac tamponade.[6][7][8] (Level of Evidence: C)"

References

  1. ↑ Gwinnutt, C., Driscoll, P. (Eds) (2003) (2nd Ed.) Trauma Resuscitation: The Team Approach. Oxford: BIOS Scientific Publishers Ltd. ISBN 978-1859960097
  2. ↑ Dolan, B., Holt, L. (2000). Accident & Emergency: Theory into practice. London: Bailliere Tindall ISBN 978-0702022395
  3. ↑ 3.0 3.1 3.2 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.
  4. ↑ Evangelista, Arturo; Isselbacher, Eric M.; Bossone, Eduardo; Gleason, Thomas G.; Eusanio, Marco Di; Sechtem, Udo; Ehrlich, Marek P.; Trimarchi, Santi; Braverman, Alan C.; Myrmel, Truls; Harris, Kevin M.; Hutchinson, Stuart; O’Gara, Patrick; Suzuki, Toru; Nienaber, Christoph A.; Eagle, Kim A. (2018). "Insights From the International Registry of Acute Aortic Dissection". Circulation. 137 (17): 1846–1860. doi:10.1161/CIRCULATIONAHA.117.031264. ISSN 0009-7322.
  5. ↑ 5.0 5.1 Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE; 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.
  6. ↑ Townsend CM, Beauchamp RD, Evers BM, et al. Sabiston Textbook of Surgery. 18th ed. Philadelphia: Elsevier Health Sciences, 2008.
  7. ↑ Libby P, Bonow RO, Mann DL, et al. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. 8th ed. Philadelphia: 2007.
  8. ↑ Isselbacher E. Cecil Medicine. 23rd ed. Philadelphia: Elsevier Health Sciences, 2008.

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