Aortic dissection

Disease Description (Causes and Symptoms)

• Definition summary: A condition in which a tear in the aortic intima allows blood to enter the media layer, separating the aortic wall into layers (aortic dissection). Classified as acute (within 2 weeks of onset) or chronic.
• Main causes: Hypertension (present in approximately 80% of patients with acute disease), connective tissue disorders (e.g., Marfan syndrome), trauma, coarctation of the aorta, medial necrosis, and others.
• Key pathophysiology: Intimal tear → formation of a false lumen between the aortic lumen and media → separated blood flow causing organ ischemia, aortic rupture, impaired cardiac/valvular function, and other complications.
• Main symptoms: Sudden, excruciating tearing pain (chest, back, or abdominal pain), syncope, dyspnea, vomiting, hypovolemic shock, unequal or absent peripheral pulses (symptoms of limb ischemia), neurological symptoms (syncope, cerebral ischemia), and others.

Treatment Methods

• Initial emergency treatment (goal: rapidly reduce blood pressure, heart rate, and shear stress)
  • Establish intravenous access and control pain with strong analgesia (usually an IV opioid).
  • Immediately administer an IV beta-blocker (e.g., esmolol, labetalol) to achieve a target heart rate of < 60 beats/minute (if possible) and reduce shear force.
  • If necessary, combine an intravenous vasodilator such as nitroprusside for additional blood pressure control after the beta-blocker has taken effect.
• Treatment principles according to definitive diagnosis and classification
  • Ascending aortic (Stanford A) dissection: Emergency surgical treatment (aortic replacement) is standard. Surgery is performed immediately after hemodynamic stabilization.
  • Isolated descending aortic (Stanford B) involvement: If there are no complications (organ ischemia, persistent pain, progression of dissection, or risk of rupture), initially manage with intensive medical treatment (strict blood pressure and heart rate control). If complications occur, TEVAR (endovascular treatment with stent-graft insertion) or open surgery may be considered.
• Surgery/procedure-related care
  • During surgery on the ascending aorta, brain and spinal cord protection techniques (deep hypothermic circulatory arrest, selective cerebral perfusion, etc.) are used.
  • During descending aortic surgery/TEVAR, adjunctive procedures and monitoring to reduce the risk of spinal cord ischemia (paraplegia) may be considered (spinal pressure decompression, temperature management, re-anastomosis, etc.).
• Long-term management
  • Lifelong blood pressure management (beta-blockers are generally recommended). The usual target systolic blood pressure is 100–120 mmHg, adjusted according to the patient’s condition.
  • Regular imaging follow-up (CTA or MRI): recommended at 1 month, 3 months, 6 months, and 12 months after the acute phase, or according to the institution’s protocol, followed by annual monitoring.
  • Avoid smoking; manage weight, exercise, and diet; if an inherited disorder (e.g., Marfan syndrome) is present, genetic counseling and family screening are recommended.

Precautions for This Disease (Precautions, Risk of Complications, and Self-Care)

• Emergency nature: Ascending aortic dissection is highly acute and potentially fatal, so anyone with suspected disease must visit an emergency department immediately.
• Complications: Aortic rupture, cardiac compression due to pericardial tamponade (cardiac tamponade), aortic regurgitation, stroke, ischemia of organs (kidneys, intestines, and limbs), paraplegia due to spinal cord ischemia, persistent vascular dilation (aneurysm formation), and others.
• Postoperative management: Monitor for infection, bleeding, and brain or spinal cord injury; adhere to prescribed antithrombotic and blood pressure medications; undergo periodic imaging follow-up.
• Lifestyle management precautions: Limit high-intensity vigorous exercise (weightlifting and strenuous activities) and excessive activity; measure blood pressure regularly and strictly follow medication instructions; if planning a pregnancy, consultation with an obstetrician-gynecologist and a cardiovascular specialist is necessary.
• Genetic predisposition: If a connective tissue disorder such as Marfan syndrome is suspected, genetic counseling is recommended (including assessment of family history).

Checklist Before an Outpatient Visit (Items to Prepare and Example Questions)

• Items to prepare
  • A complete list of current medications (including doses and administration times) and records of allergies (medications, contrast media, etc.).
  • The time of symptom onset and its course (onset, nature, and changes in pain intensity), and recent blood pressure measurements (if possible, a home blood pressure monitor log).
  • Previous test results (electrocardiogram, chest X-ray, CT/MRI image files or reports), history of surgeries and hospitalizations, and family history (aortic disease or connective tissue disorders).
  • Basic documents such as an identification card and insurance card.
• Key information to tell the healthcare provider during the outpatient visit
  • The time and nature of pain onset (whether it started suddenly and whether it felt tearing), whether syncope occurred, differences in peripheral pulses, and changes in urine output (possible renal ischemia).
  • Recent blood pressure control status and adherence to medications.

Example Questions to Ask the Doctor

• General questions
  • What are the main side effects of this medication (the prescribed antihypertensive)? What symptoms should I monitor while taking it?
  • What is the prognosis for my condition (short- and long-term survival rates and risk of recurrence)?
  • What is the schedule and criteria for follow-up imaging tests?
• Disease-specific questions (1–2)
  • Is my aortic dissection Stanford A (ascending) or Stanford B (descending)? Please explain whether surgery is urgently necessary.
  • I am planning a future pregnancy. What should I do regarding treatment and management (medication changes and prenatal care)?

(Key points for reference: CT angiography is widely used for the initial diagnosis of stable patients, while transesophageal echocardiography (TEE) is useful for rapid diagnosis in unstable patients. Emergency surgery is required when the ascending aorta is involved; when only the descending aorta is involved, medical treatment is considered first if there are no complications. Without treatment, patients with ascending aortic involvement have a high mortality rate in the short term.)