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Early Diagnosis of Aortic Dissection Key to Successful Treatment

Aortic dissection is a highly lethal condition if not recognized early and treated urgently, says Alan Braverman, MD, a Washington University cardiologist at Barnes-Jewish Hospital.

Most patients with aortic dissection report abrupt and severe pain in the chest and back, and many experience shortness of breath or pain in the arms and legs. Sometimes the symptoms can mimic more common conditions.

“While the doctor is thinking about other diseases, it can be fatal,” Braverman says. “So it’s important to think, ‘Could this be an aortic dissection?’ and do the appropriate tests early.”

Although a patient with an aortic dissection can have a normal chest X-ray, Braverman says CT scans with an intravenous contrast agent, transesophageal echocardiograms and MRI scans all have greater than 95 percent accuracy in diagnosing aortic dissection.

Once diagnosed, treatment for aortic dissection depends on the location of the tear. If it’s in the ascending aorta, the patient needs emergency surgery to repair it. Such a tear could cause bleeding around the heart, compressing the heart so it has trouble beating. An ascending dissection could also rupture into the coronary arteries and cause a heart attack or obstruct arteries to the brain and cause a stroke.

But if the tear is in the descending aorta, often surgery is not appropriate. “It’s actually riskier for patients to have emergency surgery to repair a descending dissection than to leave it alone and treat it with medication,” Braverman says. “In a descending dissection, we use medical treatment to lower blood pressure to lessen the stress and strain of the blood pulsing through the aorta. If the aorta tears all the way around, surgery only fixes the first few inches with a graft. The rest is still torn. And we watch that over a lifetime for aneurysm formation or other complications.”

A complication in a descending dissection could involve a blood vessel to a kidney or a leg. In such instances a vascular surgeon can insert a stent to protect that circulation with less risk than open surgery.

Once a patient has been diagnosed with an aortic dissection, Braverman recommends screening family members. Genetic conditions such as Marfan syndrome or a bicuspid aortic valve can run in families and are associated with a higher risk of aortic dissection. Washington University is one of about 24 sites around the world participating in the International Registry of Acute Aortic Dissections.

“This is the largest registry collecting information about aortic dissection,” Braverman says. “We collect clinical data for each patient and do a five-year follow-up. Such information has been invaluable in research in this disorder and has led to important discoveries in medical and surgical treatment for acute aortic dissection. We are fortunate at Washington University to have highly skilled cardiac surgeons, vascular surgeons and interventional radiologists with expertise in the treatment of aortic dissection. Additionally, our medical geneticists and cardiologists provide excellent genetic evaluation and long-term management.”

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