A 50-year-old man presented with 3 hours of central chest pain. Initial investigations revealed a blood pressure of 90/60 and a normal ECG. A CT angiogram showed an intimal tear and dissection in the aortic arch. The patient was transferred urgently for surgical repair of a type A aortic dissection. Aortic dissection is a tear in the aortic wall that can propagate and cause complications if not treated. Diagnosis is made through imaging like CT scans. Emergent management involves stabilizing the patient's blood pressure and transferring patients with type A dissections for surgical intervention.

1. Aortic dissection

2. Case presentation
50 yo man BIBA at 0230 with 3 hours of
dull non-radiating central chest pain.
En route, administered O2, 300mg
Aspirin, 10mg Morphine and 10mg
Metoclopramide
Pain free on arrival.

3. Previously well
No positive risk factors for IHD or PE
No regular medication or other drug
use
No trauma or recent infections

4. No prior episodes of chest pain
Vomited twice at home, and described
as clammy and pale on arrival of
ambulance, with BP 90/60 supine.

5. On arrival
Pale
Temp 37 HR 60
BP 60/40mmHg RR 14
O2 sat 100% (3L/min)
GCS 15/15
Equal radial pulses
4/6 Systolic murmur
Lungs clear to auscultation

6. ECG

7. Initial treatment
IV fluid 1L Normal saline stat
Colour improved, BP to 90/60 mmHg,
Pain free
Early investigations:
Trop T < 3 ng/L (N < 15)

8. CXR

9. Course
2nd ECG normal and Trop T < 3 at 6
hours post onset of pain
2nd litre of saline running, BP still
90/60mm/Hg, HR 60/min, with normal
peripheral perfusion
BP both arms the same
Chest pain “2/10”
Decision to order CT angiogram of chest

10. Intimal tear / flap of
dissection in aortic arch

11. 7.10AM Patient transferred to the OT
for repair of the type A dissection and
the aneurysmal dilatation of aortic root.

12. Aortic Dissection

13. Relatively uncommon (2.6-3.3/100 000 person-
years)
Initial event in aortic dissection is a tear in the
aortic intima.
Propagation of the
dissection may be
1. Proximal (retrograde)
2. Distal (antegrade)

14. Complications
Aortic valve injury with regurgitation
Pericaridal tamponade
End organ ischemia, examples
include syncope, CVA, mesenteric
or renal ischaemia.

15. Risk factors for aortic dissection
Advancing age
Male sex 2:1 (Female – pregnancy)
Systemic hypertension
Pre-existing aortic aneurysm
Atherosclerosis

16. Risk factors for under age 40
Collagen vascular disorders
Vasculitis
Bicuspid aortic valve
Aortic coarctation
Turners syndrome
Marfan syndrome
Prior aortic valve surgery
Instrumentation
Trauma
High intensity weight lifting or other exercise
Cocaine

17. Classification
Stanford
Type A –ascending Aorta
Type B – all other types / sites in aorta
DeBakey
Type I – Originates in ascending aorta,
propagates at least to the aortic arch and
often beyond it distally.
Type II – Originates / confined to the
ascending aorta.
Type III – Originates in descending aorta,
rarely extends proximally but will extend
distally.

19. Diagnosis
Routine bloods – non diagnostic
 D-dimer < 500ng/ml unlikely to be dissection
History
 Anterior chest pain in ascending aortic
dissection
 Severe sharp or tearing posterior chest or
back pain when the dissection progresses
distal to the subclavian artery

20. Pain can associated with
Syncope
Stroke
MI
Heart failure
End organ ischemia (splanchnic, renal,
extremity or spinal cord ischaemia)
Hypertension common with type B
Hypotension

21. Diagnosis of aortic dissection depends
upon demonstration of the dissection on
imaging studies
CXR
CT
MRI
TEE / TTE

22.  CT

23. Immediate management
Maintain airway, good supportive care
Treat hypotension / hypertension –
aim for MAP 60-70
Beta blockers
eg esmalol propranolol, labetalol
Vasodilators Na nitroprusside
Calcium channel blockers
eg verapamil, diltiazem

24. Management
Type A – Surgical
Type B – Surgical/medical