Clot Chronicles: Aortic Dissection

Good morning. I’m Dr. Umberto Campia, a cardiologist and vascular medicine specialist at Brigham and Women’s Hospital. I’m also an Assistant Professor of Medicine at Harvard Medical School. 

Today, we are going to talk about acute aortic dissection, a disease that affects the aorta, which is the largest vessel in the body. Aortic dissection is a relatively uncommon disease; however, it is associated with a higher risk of early mortality and a long-term risk of complications. And that’s why it’s very important that physicians are familiar with the disease, so they can recognize it early and treat it appropriately.

Aortic dissection is a form of damage to the inner wall of the aorta, and the main complication results from the detachment of the inner layer of the aorta from the outer layer. And this makes the passage of blood within the aorta restricted, and it weakens the wall. 

We can have two main types of complications. On the one side, the restricted passage of blood leads to decreased blood delivery to organs that can be associated with stroke, heart attacks, abnormal blood flow in the bowel, which we call bowel ischemia, or in the limbs, which we call limb ischemia. 

The other complication is that the outer wall that has been thinned by the detachment of the inner wall becomes weaker and is predisposed to breakage. And if that happens, one can have bleeding inside different portions of the chest or the abdomen. These complications are life-threatening. About 50% of patients who have a dissection in the portion of the aorta that’s closer to the heart had a mortality of about 50% at two weeks. That’s why it’s very important for physicians to recognize it. 

What are the symptoms and the elements that patients should keep in mind if they think that they may have an aortic dissection? The symptoms are usually associated with the acute onset of very intense pain, and the pain is usually in the chest and tends to go from the front to the back. Sometimes patients report pain in between the shoulder blades. Sometimes the pain can occur in stages, and patients sometimes may not even report the pain. But, on average, about 90% of patients do. 

Patients can also have abdominal pain or pain that travels from the upper portion of the chest to the lower portion of the chest and to the abdomen and sometimes even to the limbs. And, if pain occurs that is sudden, very intense, and has a tearing or a stabbing quality, those are the criteria that should raise a red flag and should lead to prompt medical attention, particularly if these symptoms occur in an adult or in an elderly patient. 

How do we make the diagnosis of acute aortic dissection? We now have excellent imaging modalities. The most common is the CT scan. The CT scan is available in most emergency medical centers, and it is a very quick test; within a matter of 10-15 minutes, the diagnosis can be made. And once the diagnosis is made, usually the patient needs immediate medical attention by a team of experts that know how to manage the disease and know how to minimize the risk of the deadly complications of the aorta. So usually patients are transferred, very rapidly, to an advanced aortic center (such as Brigham and Women’s Hospital). 

Once the patient arrives to the emergency room, there is usually a team that evaluates the patient and determines whether the patient needs emergency surgery—which is often the case for a dissection involving the portion of the aorta near the heart—or if treatment with a large stent placed inside the aorta to reopen the blood passage is warranted. Sometimes, even medical management with blood pressure control and pain control is what’s needed at the beginning. 

Once the initial treatment has been determined and delivered, the patient needs to be monitored closely in follow-up to prevent complications that may occur at a later stage. That’s why patients need to be followed in an advanced center with frequent imaging and with very aggressive control of blood pressure and heartrate. 

So signing off for Clot Chronicles, this is Umberto Campia. 

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