ICU · Cardiovascular

Acute aortic dissection and acute aortic syndrome

Also known as Stanford type A and type B dissection · Acute aortic syndrome · Aortic intramural haematoma (IMH) · Penetrating atherosclerotic ulcer (PAU) · TEVAR (thoracic endovascular aortic repair) · Malperfusion syndrome

Acute aortic dissection is a tear in the aortic intima allowing blood to enter the media, creating a false lumen. Stanford classification: Type A involves the ascending aorta (surgical emergency — mortality 1-2%/h, surgical repair). Type B involves only the descending aorta (medical management — BP control, TEVAR for complicated). Presentation: tearing chest/back pain, pulse deficit, BP differential (20 mmHg between arms), widened mediastinum on CXR, new aortic regurgitation murmur, neurological deficit, syncope. Diagnosis: CT angiography (gold standard — intimal flap, true/false lumen), transoesophageal echo in the unstable patient, CXR widened mediastinum as a clue. Management: Type A = emergency surgery (BP control first — beta-blocker before vasodilator, target SBP 100-120 HR 60-80); Type B = medical (IV beta-blocker first — labetalol/esmolol — reduce dP/dt, target SBP 100-120), TEVAR if complicated (malperfusion, rupture, rapid expansion — ADSORB/INSTEAD trials). Acute aortic syndrome also includes intramural haematoma (IMH) and penetrating atherosclerotic ulcer (PAU). Complications: malperfusion (coronary/cerebral/mesenteric/renal/spinal), cardiac tamponade, rupture. DeBakey classification refines anatomy (I = ascending + beyond, II = ascending only, III = descending only).