Aortic dissection

Rupture of the vasa vasorum, causing intramural haematoma, may also lead to aortic dissection. 

Where the aortic layers separate at the origins of vessels, those vessels may become occluded, resulting in ischaemia of the end-organ.

There are two methods of classification, Stanford classification (for surgery decision; Does the ascending aorta need to be operated on?) & De Bakey (for surgical planning):

Stanford Type A → Ascending aorta involved 👉 Surgery mandatory

Stanford Type B → Ascending aorta spared 👉 Medical ± endovascular

Stanford tells you WHAT TO DO. DeBakey tells you WHERE IT WENT. 

Type I – Starts in ascending, extends beyond the arch

Type II – Confined to ascending

Type III – Starts in descending 

IIIa (thoracic only)

IIIb (extends below diaphragm)

The initial event is a tear in the intima of the aorta. -> Following this, there is degeneration of the tunica media, allowing blood to pass through into the media, creating a false lumen.-> From here, the blood may track proximally or distally.-> This tracking false lumen can occlude branches of the aorta.->The occlusion of blood vessels, combined with the change in flow of blood leads to the symptoms of aortic dissection. It classically presents as tearing chest pain that radiates to the back. Immediate management includes pain relief, meticulous BP control to reduce the chance of extension-drugs that cause negative inotropic drugs have preferred. Investigation -> CT aortography.

Questions:

1. Classical presentation? Tearing type chest pain and radiating to back

2. Investigation of choice? CT Aortagram

3. Immediate treatment? Labetalol & opiates