Hypertensive Emergency in Aortic Dissection and Thoracic Aortic Aneurysm—A Review of Management (original) (raw)
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Management of patients with aortic dissection
Deutsches Ärzteblatt international, 2008
The incidence of acute diseases of the aorta will continue to rise as our population ages. Selective literature review. At centers specializing in maximum care, it is important that a specific strategy should be established in cases of clinically suspected, acute aortic diseases, and non-invasive diagnostic measures should be taken without delay. If an acute aortic dissection is diagnosed, the necessary treatment must be provided immediately. As this disease is life-threatening, a cooperating network of referring physicians and institutions should be set up in order to ensure optimal treatment for these desperately ill patients. Acute type A aortic dissections generally require surgery, while the primary treatment of uncomplicated type B dissections is conservative and complicated type B dissections can be treated primarily with stent-graft implantation. The referring medical specialists and institutions should follow the patients closely after treatment so that any problems that ma...
Diagnosis and clinical management of aortic dissection
Research Reports in Clinical Cardiology, 2014
Aortic dissection is a potentially lethal clinical entity that requires rapid diagnosis, appropriate medical management, and potential surgical intervention. Nomenclature and treatments for aortic dissection are based on the location and extent of the dissection. Aortic dissections result from an intimal tear and may occur in the ascending aorta, aortic arch, or descending aorta. Patients with aortic dissection may present with a wide variety of symptoms secondary to the pattern of dissection and end organ malperfusion. Optimal medical therapy, often using a combination of medications to achieve systolic blood pressure control is essential in management of dissection. Surgical intervention is indicated for aortic dissection of the ascending aorta and aortic arch, and in selective dissections of the descending aorta. Regardless of operative technique, the goal of surgery is to prevent progression of the dissection, restore end organ perfusion whenever possible, and prevent rapid cardiovascular collapse and death.
The International Registry of Acute Aortic Dissection (IRAD)
JAMA, 2000
Dr Evangelista), and Hospital 12 de Octubre, Context Acute aortic dissection is a life-threatening medical emergency associated with high rates of morbidity and mortality. Data are limited regarding the effect of recent imaging and therapeutic advances on patient care and outcomes in this setting.
Acute aortic dissection: Clinical characteristics and outcomes
Journal of Emergency Medicine, Trauma and Acute Care
Background: Acute aortic dissection (AAD) is a serious emergency. This prospective study aims to reveal the clinical characteristics and outcomes of medical and surgical treatments of AAD at the Ibn Al-Bitar Cardiac Centre. Methods: Over a 30-month period ending on Feb 27, 2019, 33 patients (27 males) admitted within 14 days after the onset of AAD symptoms were enrolled. The diagnosis was based on clinical findings and was confirmed by echocardiography and/or CT aortography. Intensive medical therapy was immediately initiated. Stanford classification was applied. Uncomplicated type B aortic dissections (AD) were managed conservatively while complicated type B and all type A dissections were referred for surgery. Perioperative data were entered into a Microsoft Excel-designed database, and the results were collected and statistically analyzed. Results: The male-to-female ratio was 9:2. The age range was 22-75 years, with a mean age of 48.8 ± 13.9 years. The main risk factors were hypertension (66.66%), smoking (42.42%), and Marfan's syndrome (15.15%). In 84.84% of the cases, chest pain was the presenting symptom. CT aortography revealed dissection of the thoracic aorta in 91% of the cases and the abdominal aorta in 51.5% of the cases. A total of 24 (72.7%) patients had type A AD, and 7 (21.2%) patients had type B AD, whereas two (6.1%) had Non-A Non-B categories. Among those with type B AD, 71.42% had complications. For 48.5% of the patients, surgery was offered. The overall mortality rate was 48.5%, matching the rates that had been already published. Surgery had a lower mortality rate than medical treatment (37.5% vs. 62.5%). The mortality rate of type A was higher than type B (58.3% vs. 28.6%). Conclusions: Urgent surgery performed by expert surgeons is essential to save victims of AAD primarily type A dissection.
Effectiveness of intensive medical therapy in type B aortic dissection: A single-center experience
Journal of Vascular Surgery, 2007
Objective: Although the mainstay of managing acute descending thoracic aortic dissection (ADTAD) remains medical, certain patients will require emergency surgery for complications of rupture or ischemia. This study evaluates factors that affect outcome and determines which patients previously treated surgically would have been eligible for endovascular repair. Methods: A single-institution retrospective study was conducted of patients who presented with clinical signs of ADTAD that was confirmed by magnetic resonance angiography (MRA) or computed tomography (CT). All patients were admitted to the intensive care unit (ICU) and medically managed to maintain systolic blood pressure <120 mm Hg and heart rate <70 beats/min. Two treatment groups were identified: group 1 received medical treatment only; group 2 received medical treatment plus emergency surgery. Patient demographic and clinical data were correlated with 30-day group mortality and morbidity and need for emergency surgery. The MRA and CT scan images of group 2 were retrospectively reviewed to determine if currently available endovascular treatment could have been done. The Fisher exact test was used to compare between the groups, and P < .05 was considered significant. Results: Between 1991 and 2005, 83 patients (55 men) were treated for ADTAD. The mean age was 67 years (range, 38 to 85). Sixty-eight patients (82%) had hypertension, three (3.6%) had Marfan syndrome, and 51 (62%) were smokers. Twenty-five (32%) of the patients were receiving -blocker therapy before the onset of their symptoms. Back pain was the most common initial symptom (72.2%). Emergency surgery was required in 19 patients (23%): 12 for rupture or impending rupture, four for mesenteric ischemia, and three for lower extremity ischemia. The need for emergency surgery was significantly higher in smokers (P ؍ .03), in patients >70 years old (P ؍ .035), and in patients who were not receiving -blocker therapy before the onset of symptoms (P ؍ .023). The combined overall morbidity rate was 33%, and the mortality rate was 9.6%. Morbidity in group 2 was 64% and significantly higher than the 23% in group 1 (P ؍ .00227). The mortality rate was also higher in group 2 at 31.5% compared with group 1 at 1.6% (P ؍ .0004). Factors affecting the overall mortality included age >70 years (P ؍ .057), previous abdominal aortic aneurysm repair (P ؍ .018), tobacco use (P ؍ .039), and the presence of leg pain at initial presentation (P ؍ .013). As determined from the review of radiologic data, 11 of 13 patients with scans available for review in group 2 could have been treated with currently available endovascular grafts. Conclusions: Intensive medical therapies are effective in preventing early mortality associated with ADTAD. Predictably, the need for emergency surgery carries a high morbidity and mortality rate. Most patients in this series requiring emergency surgery could have been candidates for endovascular therapy had it been available. ( J Vasc Surg 2007;45: 1114-9.)
The Annals of Thoracic Surgery, 1998
Background. We reviewed our experience in the repair of acute and chronic aortic dissection with regard to early neurologic deficit and death. Methods. Between February 1991 and June 1996, we performed 206 operations on 195 patients for aortic dissection. Ascending or arch repair, or a combination (type A dissection) was performed on 92 of 206 patients (45%); 44 of 92 (48%) were acute dissection and 48 of 92 (52%) were chronic. Descending or thoracoabdominal repair (type B dissection) was performed on 114 of 206 patients (55%); 22 of 114 (19%) were acute and 92 of 114 (81%) were chronic.
Differential Diagnosis of Chest Pain, 2019
Aortic dissection remains one of the rare but life-threatening causes of chest pain presenting to the emergency department. High index of suspicion is required for prompt diagnosis of the cases presenting to the ED. Symptoms may vary with extent and the progression of the dissection and may further complicate the diagnosis. Thus, patients may present with features of acute MI, CVA, or other end-organ ischemia. Hypertension at presentation may be an important clue for diagnosis of underlying dissection. In low risk patients, D dimer may become a useful screening tool. In patients with high index of suspicion, the choice of investigation will depend on the overall stability of the patient and extent of end-organ ischemia. Stable patients may benefit from CT angiography due to its widespread availability and speed of acquisition. Diagnosis may be challenging for hemodynamically unstable patients in centers where the resources are limited. Transesophageal echocardiography may provide diagnosis in such patients at bedside or in the emergency department. Prompt investigations are required to accurately define the type and extent of damage so that the patient receives life-saving measures in a timely manner.