Brief overview
- Symptoms: Aortic dissection results in a sharp, tearing and sometimes wandering pain behind the breastbone. Depending on its course, symptoms of, for example, a stroke or heart attack may occur.
- Treatment: Treatment depends on the site of the aortic dissection. Most often, surgery is required; less commonly, other less invasive methods may suffice.
- Risk factors: Hypertension, atherosclerosis, connective tissue diseases (e.g. Marfan syndrome), accidents, operations on the aorta and vascular diseases.
- Examination by means of a special ultrasound device (TEE) or computed tomography angiography (CTA).
What is aortic dissection?
Aortic dissection is a medical emergency. If left untreated, it is often fatal.
Many other blood vessels branch off from the aorta and supply the entire body with blood. A dissection may block some of these blood vessels. Then the part of the body supplied by them receives too little blood and no longer works properly.
In addition, the weakened aortic wall can tear in the worst case (aortic rupture). Affected patients then usually bleed to death quickly.
How does an aortic dissection manifest itself?
If the aortic wall continues to split, the pain may shift. Patients then describe “wandering” pain. Important: The pain is often less pronounced in women, the elderly or diabetics!
Contact emergency medical services immediately if you experience these symptoms! Aortic dissection is an emergency and must be treated quickly!
Further symptoms due to consequences and complications
- Stroke: If the blood supply to the carotid artery is interrupted, the brain no longer receives sufficient oxygen. Symptoms such as speech disorders or paralysis develop.
- Heart attack: Two arteries branch off from the aorta and transport blood to the heart muscle. A dissection can block them. Then oxygen no longer reaches the heart muscle and the affected person suffers a heart attack.
- Abdominal pain: If the arteries of the kidneys or intestines are blocked, very severe abdominal pain occurs. In addition, without blood, the intestines and kidneys can no longer function properly. Thus, acute kidney failure may develop.
- Pain in the extremities: Arms and legs may also be affected. The extremities ache, become pale, and can no longer be moved properly.
Parts of the airways are also close to the aorta. The expanded aorta can compress them and cut off the flow of air. Affected persons get worse air.
Internal bleeding is also a life-threatening complication. If the aortic wall ruptures close to the heart, it may also bleed into the pericardium. This so-called pericardial tamponade increasingly constricts the heart, preventing it from pumping sufficiently.
What are the different types of aortic dissection?
According to the Stanford classification, there is a type A aortic dissection and a type B aortic dissection. In type A, the inner wall of the aortic segment near the heart ruptures. This is where the aorta goes away from the heart in an upward direction (ascending portion, ascending aorta).
Type A is the more dangerous variant because important blood vessels become blocked particularly frequently. Doctors therefore always operate on a type A dissection immediately. This type is also the most common: about two-thirds of all aortic dissections belong to type A.
What is the life expectancy after an aortic dissection?
However, untreated type A aortic dissection is particularly critical. In one in two cases, it is fatal within 48 hours. A large proportion die because the aorta ruptures. After two weeks without therapy, only about one in five patients is still alive.
With every hour that passes, the risk of dying from aortic dissection increases. So alerting the emergency services immediately improves the prognosis.
Life after aortic dissection
Regular follow-up examinations are crucial for life expectancy. Doctors use computer or magnetic resonance imaging to examine the treated aorta. This allows them to react early to critical changes.
Apart from that, even small changes in everyday life can have big effects on the health of your cardiovascular system. You can read more about this in the article “Lowering blood pressure”.
Talk to your doctor about the extent to which you are allowed to exercise after an aortic dissection. Also discuss what measures are appropriate in your personal case.
Causes and risk factors of aortic dissection
If blood continues to flow into this gap, the dissection may spread in the direction of blood flow. Sometimes the blood passes through another tear back into the interior of the aorta where blood normally flows through (“true lumen”).
Risk factors
There are numerous factors that promote aortic dissection:
- Blood pressure: The most important risk factor for the development of aortic dissection is the pressure in the aorta. High pressure stresses and damages the vessel wall.
- Arteriosclerosis: In arteriosclerosis, calcium and fat deposits build up in the vessel wall. As a result, the wall loses its elasticity and is damaged more quickly.
- Drugs: Cocaine or amphetamines promote aortic dissections. It is not clear why. Drug use sometimes causes high blood pressure peaks, which in turn damage the vessel walls.
- Vascular inflammation (vasculitis): Inflammation of the aorta (aortitis) weakens its wall.
- Aortic surgeries: Damage to the aorta from previous surgery increases the risk of dissection.
- Connective tissue diseases: The structure of the aorta requires particularly elastic and strong connective tissue due to the high stress. People with certain connective tissue diseases (e.g. Marfan syndrome) are therefore more frequently affected by aortic dissection. Especially in younger patients, this is a typical cause.
How is an aortic dissection diagnosed?
The diagnosis of aortic dissection is usually made in the hospital. The first suspicion, however, is often made by the emergency physician. He interviews the patient and examines him. In most cases, the typical symptoms already indicate an aortic dissection.
Because an aortic dissection can resemble a heart attack, the doctor usually takes an ECG (electrocardiogram) before taking the patient to the hospital. In the event of an infarction, the heart currents often show typical changes. Incidentally, a heart attack can also be the result of a split aortic wall if this causes the coronary arteries to close.
In addition, they draw blood. On the one hand, this allows them to rule out other possible diagnoses. On the other hand, they get a better overview of the extent of the disease. However, there is no laboratory test specifically for aortic dissections. The D-dimer value, for example, is helpful. If this is in the normal range, it rules out an aortic dissection.
- Ultrasound from the outside: A classic ultrasound is sometimes already performed by the emergency physician, at the latest by the doctors in the emergency room. Through the rib arches (transthoracic echocardiography, TTE), they detect the heart and the aorta and possibly obtain initial indications. However, an inconspicuous TTE does not rule out aortic dissection because it is not accurate enough.
- Computed tomography (CT angiography): The diagnostic tool of choice is computed tomography with contrast. It very precisely depicts the entire aorta and the extent of the aortic dissection. At the same time, it is used for surgical planning.
How is an aortic dissection treated?
An aortic dissection is life-threatening and affected individuals always need to get to a hospital as soon as possible. Treatment begins on the way there. The emergency physician monitors and stabilizes the circulation, lowers blood pressure and heart rate, and gives pain medication.
Surgery for aortic dissection type A
Dissection of the ascending aorta is acutely life-threatening. Doctors therefore operate on such a type A aortic dissection as soon as possible. They open the chest and replace the affected section of the aorta with a plastic prosthesis. Often they also have to replace or repair the valve between the heart and the aorta.
Surgery for type B aortic dissection
Aortic dissections of the descending aorta alone (type B) are operated on by physicians primarily when complications are threatened or occur. For example, the surgery is necessary when
- pain does not improve with other measures.
- an organ is no longer supplied with blood properly.
- the aorta is in danger of rupturing (rupture).
Doctors gain access to the vascular system via the artery in the groin, which they use as a transport route. From there, they use a tube to advance the folded stent graft to the affected part of the aorta. There, they then deploy and fix the stent graft.
Treatment of aortic dissection without surgery
Dissections of the descending aorta (Stanford type B) carry a lower risk of vascular occlusion and rupture. If there is no evidence of such complications, physicians treat with medication. Here, the regulation of blood pressure and heartbeat plays a special role.
Course of treatment
Affected patients remain in the intensive care unit until they no longer have any acute symptoms and there are no indications of complications. In addition, blood pressure and heart rate must be stable even without medication via the vein.
Rehabilitation and further measures
After an aortic dissection, rehabilitation specifically for cardiovascular patients is useful. There, physicians and other therapists develop individually adapted training programs. They test the load of the individual patient and adjust the exercises under blood pressure controls.
After an aortic dissection, avoid competitive sports, sprints, weight training with sustained muscle tension and exercises with press breathing (e.g. abdominal presses)!
