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Acute Aortic Dissection and Intramural HematomaA Systematic Review

Educational Objective
To review the pathophysiology, presentation, diagnosis and treatment of acute aortic dissection and intramural hematoma.
1 Credit CME

Importance  Acute aortic syndrome (AAS), a potentially fatal pathologic process within the aortic wall, should be suspected in patients presenting with severe thoracic pain and hypertension. AAS, including aortic dissection (approximately 90% of cases) and intramural hematoma, may be complicated by poor perfusion, aneurysm, or uncontrollable pain and hypertension. AAS is uncommon (approximately 3.5-6.0 per 100 000 patient-years) but rapid diagnosis is imperative as an emergency surgical procedure is frequently necessary.

Objective  To systematically review the current evidence on diagnosis and treatment of AAS.

Evidence Review  Searches of MEDLINE, EMBASE, and the Cochrane Register of Controlled Trials for articles on diagnosis and treatment of AAS from June 1994 to January 29, 2016, were performed. Only clinical trials and prospective observational studies of 10 or more patients were included. Eighty-two studies (2 randomized clinical trials and 80 observational) describing 57 311 patients were reviewed.

Findings  Chest or back pain was the most commonly reported presenting symptom of AAS (61.6%-84.8%). Patients were typically aged 60 to 70 years, male (50%-81%), and had hypertension (45%-100%). Sensitivities of computerized tomography and magnetic resonance imaging for diagnosis of AAS were 100% and 95% to 100%, respectively. Transesophageal echocardiography was 86% to 100% sensitive, whereas D-dimer was 51.7% to 100% sensitive and 32.8% to 89.2% specific among 6 studies (n = 876). An immediate open surgical procedure is needed for dissection of the ascending aorta, given the high mortality (26%-58%) and proximity to the aortic valve and great vessels (with potential for dissection complications such as tamponade). An RCT comparing endovascular surgical procedure to medical management for uncomplicated AAS in the descending aorta (n = 61) revealed no dissection-related deaths in either group. Endovascular surgical procedure was better than medical treatment (97% vs 43%, P < .001) for the primary end point of “favorable aortic remodeling” (false lumen thrombosis and no aortic dilation or rupture). The remaining evidence on therapies was observational, introducing significant selection bias.

Conclusions and Relevance  Because of the high mortality rate, AAS should be considered and diagnosed promptly in patients presenting with acute chest or back pain and high blood pressure. Computerized tomography, magnetic resonance imaging, and transesophageal echocardiography are reliable tools for diagnosing AAS. Available data suggest that open surgical repair is optimal for treating type A (ascending aorta) AAS, whereas thoracic endovascular aortic repair may be optimal for treating type B (descending aorta) AAS. However, evidence is limited by the paucity of randomized trials.

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Article Information

Corresponding Author: Firas F. Mussa, MD, MS, Division of Vascular Surgery, Department of Surgery, Columbia University Medical Center, 161 Fort Washington Ave, Herbert Irving Pavilion, Fifth Floor, New York, NY 10032 (ffm2110@cumc.columbia.edu).

Author Contributions: Drs Mussa and Horton had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Mussa, Horton, Moridzadeh, Trimarchi, Eagle.

Acquisition, analysis, or interpretation of data: Horton, Moridzadeh, Nicholson, Trimarchi.

Drafting of the manuscript: Horton, Moridzadeh, Nicholson.

Critical revision of the manuscript for important intellectual content: Mussa, Horton, Moridzadeh, Trimarchi, Eagle.

Statistical analysis: Mussa, Horton.

Obtained funding: Mussa.

Administrative, technical, or material support: Mussa, Nicholson.

Study supervision: Mussa, Trimarchi, Eagle.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Trimarchi reports grants and personal fees from Gore and Medtronic. Dr Eagle reports grants from Gore, Medtronic, and Terumo. No other disclosures were reported.

Additional Contributions: We thank Mr G. Craig Wood, MS, for assistance with compilation and organization of the data. We also thank the contributing centers of the International Registry of Aortic Dissection (IRAD) and the coordinating center at the University of Michigan. None of these contributors received compensation.

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