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Aortic Dissection

RCEM Learning: Aortic Dissection 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

Disclaimer

There are currently no NICE guidelines on aortic dissection, therefore this article is based on European (ESC) and American (ACC/AHA) guidelines.

Background Information

Aortic dissection is a life-threatening condition:
  • Due to a tear in the aortic intima → blood flow between layers of the vessel wall
  • This creates a false lumen which can compromise blood flow and potentially rupture

Acquired causes:[ref]
  • Trauma (e.g. motor vehicle collision, during valve replacement surgery)
  • Vasculitis (e.g. aortitis in tertiary syphilis, Takayasu arteritis)

Risk factors:[ref]
  • Hypertension - most important risk factor
  • Male
  • Older age
  • Smoking
  • Use of stimulant drugs (e.g. cocaine, amphetamines)

Congenital risk factors:[ref]
  • Connective tissue disorder - Marfan syndrome, Ehlers-Danlos syndrome
  • Bicuspid aortic valve
  • Coarctation of the aorta

The Stanford classification is more important, as it is used to guide management.
 

The Stanford classification depends on whether the ascending aorta is involved or not:[ref]
 
Type Description
Stanford A Any dissection that involves the ascending aorta (irrespective of the site of origin)
Stanford B Any dissection that does NOT involve the ascending aorta (including those involving the aortic arch)

The DeBakey classification depends on the origin of the tear and the extent of the dissection:[ref]
 
Type Description
DeBakey 1 Originates in the ascending aorta + extends beyond the arch
DeBakey 2 Confined to the ascending aorta
Debakey 3 Originates in the descending aorta (distal to the left subclavian artery)
 

Patients typically present with a sudden onset of:[ref]
  • Severe chest pain (most common) / upper back pain / abdominal pain 
    • Tearing / ripping in nature
    • Maximal severity at onset

Possible examination findings:[ref]
  • Hypertension
    • Note that hypotension / shock can occur in complicated dissection
  • Aortic regurgitation features

Other concurrent presentation / complications depending on the affected vessel:[ref]
 
Artery involvement Presentation
Subclavian artery
  • Pulse deficits
    • Unequal arm pulses
    • Unequal blood pressure (>20 mmHg difference)
 
  • Arm ischaemia / claudication
Coronary artery
  • Myocardial infarction
Carotid artery
  • Stroke
  • Syncope
Mesenteric artery
  • Abdominal pain
  • Mesenteric ischaemia
Renal artery
  • Acute kidney injury
  • Haematuria
Spinal artery
  • Painless paraplegia
Iliac / fmeoral artery
  • Lower limb ischaemia

Other concurrent presentation / complications depending on the compressed structure:[ref]
 
Structure involved Presentation
Oesophagus Dysphagia
Trachea / bronchus Dyspnoea
Recurrent laryngeal nerve Hoarseness
Sympathetic chain Horner's syndrome
 
Classic presentation:
  • Type A is more likely to present with anterior chest pain.
  • Type B is more likely to present with back or abdominal pain (indicates abdominal aorta involvement).
 

Note there is a significant overlap of presentation.

Guidelines

Confirmatory test: CT angiography
  • If unstable patients  → trans-oesophageal echo can be performed first 

Recommended standard work-up in addition to definitive imaging (above):
 
Test Description
ECG For rapid exclusion of acute coronary syndrome, which can present similarly to aortic dissection and may co-exist
Chest X-ray To exclude chest pathologies

Possible chest X-ray findings in aortic dissection:
  • Mediastinal widening
  • Abnormal aortic contour
  • Pleural effusion
D-dimer Low D-dimer + low clinical risk score can be used to exclude aortic dissection

NB that elevated D-dimer is non-specific and cannot confirm the diagnosis

Management approach depends on the type of aortic dissection:
 
Aortic dissection type Management
Stanford type A Emergency surgical intervention is top priority

Concurrent medical blood pressure management is indicated during initial stabilisation (but should not delay surgicalinput)
Stanford type B 1st line: medical blood pressure management 
  • Blood control alone is sufficient for most patients

C omplicated type B dissection may require intervention:
  • 1st line: TEVAR
  • 2nd line: surgical intervention 
 

Adequate pain management is importnat (reduce sympathetic tone thus reduce heart rate)
  • Opioids are typically 1st line


Target systolic BP target <120 mmHg:  
  • Step 1: IV beta blockers ( esmolol or labetalol)
    • Alternative to beta blockers: rate-limiting CCB (verapamil or diltiazem) 
 
  • Step 2: add vasodilators (e.g. sodium nitroprusside, CCB)
    • Vasodilators should only be added once the heart rate is well controlled with a beta blocker to prevent reflex tachycardia

References

Author: Laila Moharram
Reviewer:
Last edited: 08/09/25