Aortic Dissection

What is aortic dissection?

An aortic dissection is a tear in your aorta. This is the main artery that carries oxygen-rich blood away from your heart to the rest of your body. It runs through your chest and abdomen and down to your legs. A rare condition, an aortic dissection begins abruptly when a tear happens in the inner layer of a weakened area of your aorta. Blood surges through the tear, causing the inner and middle layers (your aorta wall has three) to separate (dissect).

As diverted blood flows between the tissue layers, the normal blood flow to parts of your body may slow or stop, or your aorta may rupture completely.

Without quick diagnosis and care, an aortic dissection can cause sudden death. This is a life-threatening condition. Get emergency treatment right away. You may feel scared, but first responders will know what to do.

Each year, 5 to 30 people per 1 million have an aortic dissection.

Types of aortic dissection

There are two main aortic dissection types:

• Stanford Type A Aortic Dissection: This type starts in the first (upper) part of your aorta, closer to your heart. It can be immediately life-threatening. It usually requires emergency open-chest surgery to repair or replace the first part of the aorta where the tear started. The dissection usually extends through the entire length of the aorta. This is a more common type than Type B.
• Stanford Type B Aortic Dissection: This type begins farther down your aorta (descending aorta beyond the arch), and farther from your heart. Like the Type A dissection, this usually extends from the descending aorta into your abdominal aorta. But it doesn’t involve the first part of the aorta. You may or may not need surgery right away, depending on where the dissection is and whether it’s cutting off blood flow to your organs.

Healthcare providers also use the DeBakey classification system, which has three types. Type 1 starts in your ascending aorta and extends through your descending aorta. Type 2 starts in and is limited to the ascending aorta (both would be considered Stanford Type A). Type 3 starts in your descending aorta and extends downward (like Type B).

What are the symptoms?

The most common feature of aortic dissection is its abrupt start. It can happen at any time, most commonly from a sudden rise in blood pressure with heavy exertion. But it can occur while doing anything, at rest or when you’re sleeping. There are no aortic dissection warning signs.

Common aortic dissection symptoms you may experience include:

• Sudden severe, sharp pain in your chest or upper back. This may be a tearing, stabbing or ripping feeling.
• Severe pain in your belly.
• Shortness of breath (dyspnea).
• Fainting or dizziness.
• Low blood pressure.
• Diastolic heart murmur or muffled heart sounds.
• Rapid weak pulse.
• Heavy sweating.
• Confusion.
• Loss of vision.
• Stroke symptoms, including weakness or paralysis on one side of your body or trouble talking.

If you have symptoms of aortic dissection, severe chest pain or symptoms of a stroke, call 911 or your local emergency services number, or seek emergency care.

What causes aortic dissection?

Aortic dissection happens because there’s a slow breakdown of the cells in the walls of your aorta. The breakdown has likely been going on silently for many years before the weakened area of the aortic wall finally gives way. This results in a tear, which leads to the aortic dissection.

Healthcare providers believe that a basic weakness in the aortic wall (possibly inherited) causes most aortic dissections. In other cases, the stress from constant high blood pressure can weaken the aorta wall. This can lead to a tear and dissection.

Tears in the aorta typically occur in areas where the stress on the wall of the aorta is highest, like your ascending aorta. Aortic dissection in the ascending aorta is nearly two times more common than those that happen in the descending aorta.

What are the risk factors for aortic dissection?

Factors that can increase your risk of an aortic dissection include:

• Ongoing high blood pressure (hypertension). This is the most important and most common risk factor. High blood pressure directly damages the layers of aortic tissue. This causes a loss of elastic fibers, breakdown of the wall structure and increased wall stiffness.
• Atherosclerosis (plaque buildup in your arteries) or high cholesterol.
• Tobacco product use.
• Aortic aneurysm (an abnormal enlargement or bulge in your aortic wall).
• Aortic valve disease.
• Congenital (present at birth) heart conditions like a bicuspid aortic valve (has two leaflets instead of the normal three) or Turner syndrome.
• Connective tissue disorders like Marfan syndrome and Ehlers-Danlos syndrome. These are problems that biological parents can pass down to their children.
• Other hereditary thoracic aortic conditions that primarily affect your aorta.
• Family history of aortic dissection.
• Aortitis (inflamed aorta).
• Traumatic injury to your chest like a high-speed car crash or serious fall from a height of more than 20 feet.
• Being assigned male at birth (AMAB).
• Age between 40 and 70 years. The aortic wall loses its elasticity with age.
• Pregnancy with high blood pressure during delivery.
• Activities that extend periods of high blood pressure, like cocaine or amphetamine use.

Powerlifting may increase how quickly aneurysms or dissection develop in people who are prone to them.

If you have high-risk factors (like aneurysms or a connective tissue disorder), look for an aortic center of excellence for your care. These centers have access to the latest innovations for treatment. They also offer the best in multidisciplinary care (including cardiologists, imaging specialists and geneticists). Multiple studies have demonstrated that centers that treat a lot of aortas provide the best outcomes for these complex cases.

What are the complications of aortic dissection?

Aortic dissection can lead to:

• Stroke.
• Aortic valve damage.
• Heart attack.
• Heart failure.
• Damage to internal organs, like your kidneys.
• Cardiac tamponade, a fluid buildup between your heart muscle and the sac around your heart (pericardium).
• Death.

How is aortic dissection diagnosed?

A provider may suspect an aortic dissection based on the symptoms you’re having. But they need to determine if you have aortic dissection or other health issues, like heart attack and stroke, which produce similar symptoms. With aortic dissection, it may be hard to find a pulse in your arms and legs. A provider may find that the blood pressure in one arm is higher than the other.

Providers need to diagnose aortic dissection quickly in case you need immediate surgery. When your team makes an aortic dissection diagnosis, a critical care transport team may transfer you to a center that manages these complex conditions.

What tests will be done to diagnose aortic dissection?

A provider may order tests including:

• Chest X-ray: This quick test uses a small amount of radiation to create an image of the structures in your chest, including your heart, lungs, blood vessels (like your aorta) and bones.
• Computed tomography (CT) scan: This test quickly provides the best view of your aorta during an emergency so a provider can look for an aneurysm or dissection. You may receive intravenous (IV) contrast in your vein as part of the test.
• Transthoracic echocardiogram (TTE): This test uses ultrasound to provide moving pictures of your heart valves and chambers and the first portion of the aorta (the aortic root).
• Transesophageal echocardiogram (TEE): This test shows more detailed pictures of your heart valves and chambers than a transthoracic echocardiogram. It also offers better views of your thoracic aorta. A provider places the ultrasound probe through your mouth and into your esophagus, which runs directly behind your heart and in front of your descending aorta.
• Magnetic resonance imaging (MRI): This test uses a large magnet and radio waves to produce detailed images of your organs and the structures inside your body, including your aorta. It provides moving pictures of your heart valves and chambers and blood flow through your aorta. This test may take longer than a typical CT scan, so providers use it less often in emergencies.

How is aortic dissection treated?

Aortic dissection treatment depends on the location of the tear and dissection.

• For Type A aortic dissection (when it involves the first part of the aorta close to your heart), you need immediate surgery.
• For Type B aortic dissection, you need emergency surgery if the dissection cuts off blood flow to your vital organs and body parts. These include your kidneys, intestines, legs or spinal cord. You need urgent surgery if your CT scan shows certain high-risk features. For less severe cases, aortic dissection treatments may start with medication to slow your heart rate or lower your blood pressure. You may have surgery later if complications develop.

Surgery and endovascular treatment

Surgical options include:

• Graft replacement: A surgeon removes a portion of the damaged section of your aorta and sews a synthetic fabric tube (graft) directly in its place. Depending on the extent of the dissection, they may also need to repair your aortic valve, aortic root or your aortic arch and the vessels that go to your arms and head. This involves open-heart surgery and is the treatment of choice for an acute Type A aortic dissection.
• Endovascular stent-graft repair: A provider repairs your aorta from within by using a stent graft — a synthetic fabric tube with metal wire stents for support (like a scaffold). The stent relines and reinforces the weak area in your aorta. For an acute Type B dissection that’s complicated (blood flow cut off to important organs or with high-risk features on a CT scan), endovascular repair is the approach of choice. A provider performs an endovascular repair with wires and catheters by accessing the femoral artery at your groin through a small incision.
• Hybrid approach: A provider uses open surgery and endovascular stent-graft techniques to repair your aorta. They use this approach when the repair must extend into the aortic arch where branch vessels to the brain and arms arise. They may perform this during the emergency operation for Type A dissection. Also, it can be part of a two-stage repair with a bypass from a vessel in your neck to help set up an endovascular repair for Type B dissection.

Medications

A provider may prescribe medications like beta-blockers to lower your heart rate and blood pressure. In some Type B aortic dissection cases, they may use medication alone to treat the dissection at first. A provider may delay surgery for months to years depending on the severity of the tear and extent of dissection.

Can aortic dissection be prevented?

You can’t change many of the factors that increase the risk of developing aortic dissection. These include being born with certain heart conditions, connective tissue disorders, or genetic triggers associated with having a family history of aortic dissection.

But you can decrease some of your risks by:

• Managing your blood pressure.
• Avoiding tobacco products.
• Maintaining a weight that’s healthy for you.
• Wearing your seat belt to prevent injury to your chest in case of an accident.
• Seeing your provider for regular checkups and any other times you have a change in your health.
• Asking a provider to assess your risk of aortic disease if a first-degree relative (parent, child or sibling) has had an aortic dissection. A provider can monitor and treat you before an aortic event occurs.

If you get an aortic aneurysm diagnosis, seek out a healthcare provider (cardiologist or cardiac surgeon) who specializes in aortic disease. They’ll be able to assess your risks and use imaging to carefully monitor you for the need for elective repair of your aorta.

What can I expect if I have aortic dissection?

Aortic dissection can be a life-threatening event. People who have acute aortic dissection (sudden onset, Type A) have a high death rate. About 40% of people with Type A aortic dissection die immediately from complete rupture and bleeding out from their aorta.

People who survive the acute phase usually have a chronic dissection remaining in the untreated portions of their aorta. This may require later treatment.

With modern advances in care, the prognosis (outlook) in the chronic phase is improving. But life expectancy after aortic dissection is shorter compared to the general population. Still, with early treatment and management by a trained aortic team, people can live normal lives for many, many years after an aortic dissection.

How do I take care of myself?

A provider will prescribe blood pressure medicine, usually beta-blockers, to manage your blood pressure and heart rate. You’ll need to take them for the rest of your life. You may need more than one blood pressure medication.

Avoiding tobacco products is important after an aortic dissection, too.

It’s OK to do aerobic activities like walking, biking and swimming. But you’ll need to avoid certain activities, like heavy weightlifting (more than half your body weight). They can increase your blood pressure and put added stress on your aorta.

When should I see my healthcare provider?

When you survive aortic dissection — even if you don’t have surgery — you need to see a provider regularly (usually, every three to 12 months) for follow-up imaging with a CT or MRI. This allows providers to catch changes and act on them quickly.

What questions should I ask my healthcare provider?

Questions you may want to ask your provider include:

• Which type of aortic dissection do I have?
• Will I need surgery?
• Can you refer me to a support group for people who’ve had an aortic dissection?

What’s the difference between aortic aneurysm, aortic rupture and aortic dissection?

An aortic aneurysm is a bulge — like a bubble or a balloon — in a weakened area of the wall of your aorta or across an entire segment of your aorta. Aortic aneurysm can lead to aortic rupture and aortic dissection.

An aortic rupture is a complete tear through all three layers of the aorta — like a rip or a hole — in the wall of your aorta. Blood bursts through the hole into the area around it.

An aortic dissection is a tear in the inner aortic layer. It allows blood to enter and further separate the inner and middle layers of the wall of the aorta. It typically extends over a long length of your aorta in either direction and may extend into branch vessels that start in your aorta.