Overview

Aortic dissection is the most common catastrophe

of the aorta, 2-3 times more common than rupture
of the abdominal aorta. When left untreated, about
33% of patients die within the first 24 hours, and
50% die within 48 hours. The 2-week mortality rate
approaches 75% in patients with undiagnosed
ascending aortic dissection.

The establishment of the International Registry of
Acute Aortic Dissection in 1996, which gathers
information from 24 centers in 11 countries, has
helped in the development of an understanding of
the complexity of aortic dissection.

Dissections of the thoracic aorta have been
classified anatomically by 2 different methods. The
more commonly used system is the Stanford
classification, which is based on involvement of the
ascending aorta and simplifies the DeBakey
classification.

Go to Aortic Dissection for complete information
on this topic.

Stanford classification
The Stanford classification divides dissections into
2 types, type A and type B. Type A involves the
ascending aorta (DeBakey types I and II); type B
does not (DeBakey type III).

This system helps to delineate treatment. Usually,
type A dissections require surgery, while type B
dissections may be managed medically under most
conditions.

DeBakey classification
The DeBakey classification divides dissections into
3 types, as follows:

Type I involves the ascending aorta, aortic arch,
and descending aorta
Type II is confined to the ascending aorta
Type III is confined to the descending aorta distal
to the left subclavian artery
Type III dissections are further divided into IIIa
and IIIb. Type IIIa refers to dissections that
originate distal to the left subclavian artery but
extend proximally and distally, mostly above the
diaphragm.
Prezentare general
Disecie aortic este cea mai frecventa catastrofa de
aorta , de 2-3 ori mai frecvente dect ruptura de
aorta abdominala . Atunci cnd este lasata netratata
, aproximativ 33 % dintre pacienti mor in primele
24 de ore , iar 50 % mor n termen de 48 de ore.
Rata mortalitii de 2 sptmni, se apropie de 75
% la pacientii cu nediagnosticate disectie aortica
ascendenta .

nfiinarea Registrului internaional de disectie
aortica acuta in 1996 , care adun informaii de la
24 de centre in 11 de tari, a contribuit la
dezvoltarea de o nelegere a complexitii de
disectie aortica .

Disecii aleaortei toracice au fost clasificate
anatomic prin 2 metode diferite . Sistemul mai
frecvent utilizat esteclasificarea Stanford , care se
bazeaz pe implicareaaortei ascendente i
simplificclasificarea DeBakey .

Du-te la disectie aortic pentru informaii complete
privind acest subiect .

clasificarea Stanford
Clasificarea Stanford mparte disecii n 2 tipuri ,
de tip A i de tip B. Tipul A implic aorta
ascendent ( tipuri DeBakey I i II ) , de tip B nu (
DeBakey tip III ) .

Acest sistem ajut la delimita tratament . De obicei
, tip A disecii necesita o interventie chirurgicala ,
in timp ce disecii de tip B pot fi gestionate medical
n cele mai multe condiii .

clasificarea DeBakey
Clasificarea DeBakey mparte disecii n 3 tipuri ,
dup cum urmeaz :

Tipul I implic aorta ascendent , arcul aortic , i
aorta descendenta
Tip II este limitat laaorta ascendent
Tip III se limiteaz laaortei descendente distal de
artera subclavie stnga
Tip III disecii sunt n continuare mprite n IIIa i
IIIb . Tip IIIa se refer la disecii care provin distal
de artera subclavie stnga , dar extinde proximal i
distal , mai ales deasupra diafragmei .

Tip IIIb se refer la disecii care provin distal de

Type IIIb refers to dissections that originate distal
to the left subclavian artery, extend only distally,
and may extend below the diaphragm.

Thoracic aortic dissections should be distinguished
from aneurysms (ie, localized abnormal dilation of
the aorta) and transections, which are caused most
commonly by high-energy trauma.

Prehospital Care
Assure adequate breathing, maintain oxygenation,
treat shock, and obtain useful historical
information.

Establishing the diagnosis in the field is usually
difficult or impossible, but certain salient features
of aortic dissection may be observed. It is life
threatening if not quickly recognized and treated.

Radio communication with the receiving hospital
permits the medical control physician to direct care
and select a capable destination hospital, while
permitting the emergency department (ED) to
mobilize appropriate resources.

In the rare event that the diagnosis can be made
based on prehospital information, the physician
directing prehospital care should request transport
to a facility capable of operative treatment of an
aortic dissection.

Emergency Department Care
The mortality rate of patients with aortic dissection
is 1-2% per hour for the first 24-48 hours. Initial
therapy should begin when the diagnosis is
suspected. This includes 2 large-bore intravenous
lines (IVs), oxygen, respiratory monitoring, and
monitoring of cardiac rhythm, blood pressure, and
urine output.

Clinically, the patient must be assessed frequently
for hemodynamic compromise, mental status
changes, neurologic or peripheral vascular changes,
and development or progression of carotid,
brachial, and femoral bruits.

Aggressive management of heart rate and blood
pressure should be initiated.

Beta blockers should be given initially to reduce
artera subclavie stnga , extinde doar distal , i se
poate extinde sub diafragm .

Disectii aortice toracice ar trebui s fie deosebit de
anevrisme ( de exemplu , dilatarea anormal
localizat a aortei ) i transections , care sunt
cauzate cel mai frecvent de traumatisme de nalt
energie .

ngrijirea prespitaliceasc
Asigurarea respiraie adecvat , menine oxigenarea ,
trata oc , i de a obine informaii istorice utile .

Stabilirea diagnosticului n domeniul de obicei este
dificil sau imposibil , dar anumite caracteristici
importante ale disectie aortica pot fi observate .
Acesta este n pericol viaa dac nu rapid
recunoscute i tratate .

Comunicaii radio cu spitalul a primit permite
medicului de control medical pentru ngrijirea
direct i selectai un spital destinaie capabil ,
permind n acelai timp departamentul de urgenta
( ED ) de a mobiliza resursele adecvate .

n rarele cazuri care diagnosticul se poate face pe
baza informaiilor prespital , medicul regie de
ngrijire prespitaliceti trebuie s solicite de
transport la o instalaie capabil de tratament
operativ de o disectie aortic .

Departamentul de asistenta de urgenta
Rata de mortalitate a pacienilor cu disectie aortica
este 1-2 % pe ora in primele 24-48 de ore . Terapie
iniial ar trebui s nceap atunci cnd se
suspecteaz diagnosticul . Aceasta include 2 linii de
mare cu teava intravenoase (IVS ) , oxigen ,
monitorizare respiratorie , i monitorizarea ritmului
cardiac , a tensiunii arteriale , i diurezei .

Punct de vedere clinic , pacientul trebuie s fie
evaluat frecvent pentru compromis hemodinamice ,
modificri ale statusului mental , modificri
vasculare neurologice sau periferice , precum i
dezvoltarea sau progresia bruits carotide , brahial ,
i femurale .

Ar trebui s fie iniiat de management agresiv al
ritmului cardiac si a tensiunii arteriale .

Beta-blocantele trebuie acordat iniial pentru a
the rate of change of blood pressure (dP/dt) and the
shear forces on the aortic wall.

The target heart rate should be 60-80 beats per
minute.

The target systolic blood pressure should be 100-
120 mm Hg.

End organ perfusion should be evaluated.
Balancing the risks of dP/dt on the aortic wall
versus the benefits of acceptable end organ
perfusion may be a difficult clinical decision.

Retrograde cerebral perfusion may increase the
protection of the central nervous system during the
arrest period.

The mortality rate from aortic arch dissections is
about 10-15%, with significant neurologic
complications occurring in another 10% of patients.
The mortality rate is influenced by the patient's
clinical condition.

The American College of Radiology has
established ACR Appropriateness Criteria for the
diagnosis and treatment of suspected aortic
dissection.[1]

Type A dissections
Urgent surgical intervention is required in type A
dissections.

The area of the aorta with the intimal tear usually is
resected and replaced with a Dacron graft.

The operative mortality rate is usually less than
10%, and serious complications are rare with
ascending aortic dissections.

The development of more impermeable grafts, such
as woven Dacron, collagen-impregnated
Hemashield (Meadox Medicals, Oakland, NJ),
aortic grafts, and gel-coated Carbo-Seal Ascending
Aortic Prothesis (Sulzer CarboMedics, Austin,
Tex), has greatly enhanced the surgical repair of
thoracic aortic dissections.

With the introduction of profound hypothermic
circulatory arrest and retrograde cerebral perfusion,
the morbidity and mortality rates associated with
reduce rata de schimbare a tensiunii arteriale ( DP /
dt) i forele de forfecare pe perete aortic .

Ritmul cardiac int ar trebui s fie 60-80 de batai
pe minut .

Valoarea int a tensiunii arteriale sistolice ar trebui
s fie de 100-120 mm Hg .

Perfuzia organelor final ar trebui s fie evaluat .
Echilibrarea riscurile de dP / dt pe peretele aortic
fa de beneficiile de perfuzie acceptabile de
organe final poate fi o decizie clinic dificil .

Perfuziei cerebrale retrograd poate crete de
protecie a sistemului nervos central n timpul
perioadei de arest .

Rata mortalitii din arcul aortic disectii este de
aproximativ 10-15 % , cu complicatii neurologice
importante care apar ntr-un alt 10 % din pacienti .
Rata de mortalitate este influenat de starea clinic
a pacientului .

Colegiul American de Radiologie a stabilit ACR
Criterii de adecvare pentru diagnosticul i
tratamentul de disecie aortic suspectate . [ 1 ]

De tip A disecii
Intervenie chirurgical de urgen este necesar tip
A disecii .

Zona de aorta cu ruptura intimei , de obicei, este
rezecat i nlocuit cu o grefa Dacron .

Rata de mortalitate operatorie este de obicei mai
puin de 10 % , iar complicaii grave sunt rare, cu
ascendent disectii aortice .

Dezvoltarea de grefe mai impermeabile , cum ar fi
esute Dacron , Hemashield ( Medicals Meadox ,
Oakland , NJ) , grefe aortice , i gel - strat Carbo -
Seal Ascendent Prothesis aortica ( CarboMedics
Sulzer , Austin , Tex ) , colagen - impregnate -a
mbuntit foarte mult repararea chirurgicale de
disectii aortice toracice .

Odat cu introducerea de profund arestarea
circulator hipotermic i a perfuziei cerebrale
retrograde , ratele de morbiditate i mortalitate
asociate cu aceasta operatie foarte invazive s-au
this highly invasive surgery have decreased.

Dissections involving the arch are more
complicated that those involving only the
ascending aorta, because the innominate, carotid,
and subclavian vessels branch from the arch. Deep
hypothermic arrest usually is required. If the arrest
time is less than 45 minutes, the incidence of
central nervous system complications is less than
10%.

Aortic stent grafting is a challenging technique. It
may prove feasible and has offered good results in
a small series of patients. It may be a reasonable
alternative in high-risk patients in the near future.

Type B dissections
The definitive treatment for type B dissections is
less clear.

Uncomplicated distal dissections may be treated
medically to control blood pressure. Distal
dissections treated medically have a mortality rate
that is the same as or lower than the mortality rate
in patients who are treated surgically.

Surgery is reserved for distal dissections that are
leaking, ruptured, or compromising blood flow to a
vital organ.

Acute distal dissections in patients with Marfan
syndrome usually are treated surgically.

Inability to control hypertension with medication is
also an indication for surgery in patients with a
distal thoracic aortic dissection.

Patients with a distal dissection are usually
hypertensive, emphysematous, or older.

Long-term medical therapy involves a beta-
adrenergic blocker combined with other
antihypertensive medications. Avoid
antihypertensives (eg, hydralazine, minoxidil) that
produce a hyperdynamic response that would
increase dP/dt (ie, alter the duration of P or T
waves).

Survivors of surgical therapy also should receive
beta-adrenergic blockers.

diminuat .

Disecii implic arcului sunt mult mai complicate
pe care cei care implic doar aorta ascendenta ,
deoarece brahiocefalic , carotid , i filiala
subclavie nave de la arc . Arestarea profund
hipotermic , de obicei, este necesar . Dac timpul
de stop este mai mic de 45 de minute,incidena
complicaiilor sistemului nervos central este mai
mic de 10 % .

Stent aortice altoire este o tehnic dificil . Se poate
dovedi fezabil i a oferit rezultate bune ntr -o serie
mic de pacieni . Acesta poate fi o alternativa
rezonabila la pacientii cu risc ridicat , n viitorul
apropiat .

Tip B disecii
Tratamentul definitiv de tip B disectii este mai
puin clar .

Disecii distale necomplicate pot fi tratate medical
pentru controlul tensiunii arteriale . Disecii distale
tratat medical au o rat de mortalitate , care este la
fel sau mai mic dect rata mortalitii la pacienii
care sunt tratai chirurgical .

Chirurgia este rezervata pentru disecii distale care
sunt scurgeri , rupt , sau de a compromite fluxul de
sange la un organ vital .

Disecii distale acute la pacientii cu sindromul
Marfan , de obicei, sunt tratate chirurgical .

Incapacitatea de a controla hipertensiunea arterial
cu medicamente este , de asemenea, un indiciu
pentru interventii chirurgicale la pacientii cu
disectie distala toracice aortica .

Pacientii cu o disectie distala sunt de obicei
hipertensivi , emphysematous , sau mai mari .

Tratament medical pe termen lung implic un
blocant beta- adrenergic combinat cu alte
medicamente antihipertensive . Evita
antihipertensive (de exemplu , hidralazin ,
minoxidil ) care produc un rspuns hiperdinamice
care ar crete dP / dt ( adic , modificareaduratei
undelor P sau T ) .

Supravieuitorii de tratamentul chirurgical , de
A series of patients with type B dissections
demonstrated that aggressive use of distal
perfusion, CSF drainage, and hypothermia with
circulatory arrest improves early mortality and
long-term survival rates.

Endovascular stenting remains an option for
treatment of some type B dissections. Some studies
recommend that patients with complicated acute
type B dissections undergo endovascular stenting
with the goal of covering the primary intimal
tear.[2]

Definitive treatment
Definitive treatment involves segmental resection
of the dissection, with interposition of a synthetic
graft.

When thoracic dissections are associated with
aortic valvular disease, replace the defective valve.

With combined reconstructionvalve replacement,
the operative mortality rate is approximately 5%,
with a late mortality rate of less than 10%.

Operative repair of the transverse aortic arch is
technically difficult, with an operative mortality
rate of 10% despite induction of hypothermic
cardiocirculatory arrest.

Repair of the descending aorta is associated with a
higher incidence of paraplegia than repair of other
types of dissections because of interruption of
segmental blood supply to the spinal cord.

The operative mortality rate is approximately 5%.

In a study by Mimoun et al of patients with Marfan
syndrome who had acute aortic dissection, the
patients were found to have a better event-free
survival when there were no dissected portions of
the aorta remaining after surgery.[3]

Consultations
Once a thoracic dissection is suspected, consult a
thoracic surgeon. Because many patients with this
disorder have concomitant medical illness, consult
the patient's primary care provider to expedite
preoperative preparation. Early consultation is
encouraged when ordering further imaging studies
if the patient requires rapid operative intervention.
asemenea, ar trebui s primeasc beta - blocante
adrenergice .

O serie de pacienti cu disectii de tip B, au
demonstrat c utilizarea agresiv a perfuziei distale
, drenajul LCR , i hipotermie cu arestarea
circulator imbunatateste mortalitatea precoce si
ratele de supravietuire pe termen lung .

Stentare endovasculare ramane o optiune pentru
tratamentul unor disectii de tip B . Unele studii
recomanda ca pacientii cu complicate disectii de tip
B acute supuse stent endovasculare cu scopul de a
acoperi ruptura intimei primar . [ 2 ]

tratament definitiv
Tratamentul definitiv implic rezecia segmental de
disectie , cu interpunerea de o grefa sintetic .

Cnd disecii toracice sunt asociate cu boala
valvulara aortica , nlocuii supapa defect .

Cu nlocuire reconstrucia supape combinat ,rata
mortalitii operativ este de aproximativ 5 % , cu o
rat de mortalitate trzie a mai puin de 10 % .

Repararea operativ a arcului aortic transversal este
punct de vedere tehnic dificil , cu o rat de
mortalitate operatorie de 10 % , n ciuda inducerea
de arestare cardiocirculatorii hipotermic .

Repararea aorta descendenta este asociat cu o
incidenta mai mare de paraplegie dect repararea
altor tipuri de disectii cauza de ntrerupere a
alimentrii cu snge segmente de maduva spinarii .

Rata de mortalitate operatorie este de aproximativ 5
% .

ntr-un studiu de Mimoun et al pacientilor cu
sindrom Marfan , care a avut disectie de aorta ,
pacientii s-au dovedit a avea o mai buna de
supravietuire fara evenimente atunci cnd nu s-au
disecat poriuni ale aortei rmase dup intervenia
chirurgical . [ 3 ]

consultri
Odat ce o disectie toracica este suspectat ,
consulta un chirurg toracic . Deoarece multi
pacienti cu aceasta tulburare au boli concomitente
medicale , consultai pacientului de ingrijire

Consult a radiologist prior to obtaining
aortography.

Inpatient Care
Patients with symptomatic dissection should
undergo immediate repair, especially if it is leaking
or expanding.

Symptomatic patients require admission to a center
experienced in cardiopulmonary bypass and
operative care.

Completely asymptomatic patients may have their
repair performed electively but may require
admission to expedite their evaluation or for
preoperative stabilization of their condition.

Patients with chest pain should undergo serial
echocardiograms (ECGs) and creatine kinase (CK)
determinations if acute myocardial infarction
(AMI) is indicated.

Outpatient Care
Follow-up examinations with radiologic studies are
recommended at 3-month intervals for the first year
and every 6 months for the next 2 years.

After this, follow up annually.

Transfer
Symptomatic patients require care at a facility
equipped to perform cardiopulmonary bypass with
aortic and/or valvular repair.

Contact the receiving physician as soon as possible
to transfer patients before their condition
deteriorates.

Early airway management is indicated in the
presence of hemoptysis or stridor.

If coronary insufficiency is suspected, nitrates may
be used, but therapy with thrombolytic agents and
aspirin should be avoided.

Patients should be monitored and accompanied by
personnel capable of resuscitation.

If a prolonged ground transport time is anticipated,
consider air transport.
primara de a accelera pregtire preoperatorie .
Consultare devreme este ncurajat atunci cnd
comanda studii suplimentare imagistica cazul n
care pacientul necesit intervenie operativ rapid
.

Consulte un radiolog nainte de obinerea
aortografie .

staionar
Pacientii cu disectie simptomatic ar trebui s fac
reparaii imediate , mai ales dac acesta este
scurgeri sau extinde .

Pacienii simptomatici nevoie de admitere la un
centru de experien n by-pass cardiopulmonare i
operative de ingrijire .

Complet asimptomatici pot avea repararea acestora,
realizat prin alegere , dar poate solicita admiterea
pentru a accelera evaluarea lor sau pentru
stabilizarea preoperatorie de starea lor .

Pacienii cu durere in piept ar trebui s se supun
ecocardiograme de serie ( ECG ) i creatinkinazei (
CK ) determinri , dac este indicat infarct
miocardic acut ( IMA ) .

ambulatoriu
Follow - up examene cu studii radiologice se
recomand la intervale de 3 luni pentru primul an i
la fiecare 6 luni pentru urmtorii 2 ani .

Dup aceasta , urmarire anual .

transfer
Pacienii simptomatici necesita ingrijire la o
instalaie echipate pentru a efectua by-pass
cardiopulmonare cu aortic i / sau reparare
valvulara .

Contactai medicul primete ct mai curnd posibil
pentru a transfera pacientii inainte de starea lor se
deterioreaza .

De gestionare a cailor aeriene precoce este indicat
n prezena hemoptizie sau stridor .

Dac se suspecteaz insuficien coronarian , pot
fi utilizate nitrai , dar terapia cu medicamente
trombolitice i aspirin trebuie evitat .

Pacienii trebuie monitorizai i nsoite de personal
capabil de resuscitare .

n cazul n care un timp prelungit de transport la sol
se anticipeaz , ia n considerare transportul aerian .