Answer
The American College of Radiology has established ACR Appropriateness Criteria for the diagnosis and treatment of suspected aortic dissection. [5]
Type A dissections
Urgent surgical intervention is required in type A dissections. The area of the aorta with the intimal tear usually is resected and replaced with a Dacron graft. The operative mortality rate is usually less than 10%, and serious complications are rare with ascending aortic dissections.
The development of more impermeable grafts, such as woven Dacron, collagen-impregnated Hemashield (Meadox Medicals, Oakland, NJ), aortic grafts, and gel-coated Carbo-Seal Ascending Aortic Prothesis (Sulzer CarboMedics, Austin, Tex), has greatly enhanced the surgical repair of thoracic aortic dissections.
With the introduction of profound hypothermic circulatory arrest and retrograde cerebral perfusion, the morbidity and mortality rates associated with this highly invasive surgery have decreased.
Dissections involving the arch are more complicated than those involving only the ascending aorta, because the innominate, carotid, and subclavian vessels branch from the arch. Deep hypothermic arrest usually is required. If the arrest time is less than 45 minutes, the incidence of central nervous system complications is less than 10%.
Aortic stent grafting is a challenging technique. It may prove feasible and has offered good results in a small series of patients. It may be a reasonable alternative in high-risk patients in the near future.
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Aortic dissection
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Chest radiograph of a patient with aortic dissection. Image courtesy of Dr. K. London, University of California at Davis Medical Center.
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Chest radiograph of a patient with aortic dissection presenting with hemothorax.
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Chest radiograph demonstrating widened mediastinum in a patient with aortic dissection.
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Angiogram demonstrating dissection of the aorta in a patient with aortic dissection presenting with hemothorax.
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Electrocardiogram of a patient presenting to the ED with chest pain; this patient was diagnosed with aortic dissection.
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Patient with an ascending type A aortic dissection showing the intimal flap. Image courtesy of Kaiser-Permanente.
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Patient with an ascending type A aortic dissection showing the intimal flap. Image courtesy of Kaiser-Permanente.
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Patient with an ascending type A aortic dissection showing the intimal flap. Image courtesy of Kaiser-Permanente.
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Patient with an ascending type A aortic dissection showing the intimal flap. Image courtesy of Kaiser-Permanente.
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Patient with a type A aortic dissection involving the ascending and descending aorta. Image courtesy of Kaiser-Permanente.
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Patient with a type A aortic dissection involving the ascending and descending aorta. Image courtesy of Kaiser-Permanente.
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Patient with a type A aortic dissection involving the ascending and descending aorta. Image courtesy of Kaiser-Permanente.
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Patient with a type A aortic dissection involving the ascending and descending aorta. Image courtesy of Kaiser-Permanente.
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Patient showing a type B aortic dissection with extravasation of blood into the pleural cavity. Image courtesy of Kaiser-Permanente.
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Patient showing a type B aortic dissection with extravasation of blood into the pleural cavity. Image courtesy of Kaiser-Permanente.
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Patient showing a type B aortic dissection with extravasation of blood into the pleural cavity. Image courtesy of Kaiser-Permanente.
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Patient showing a type B aortic dissection with extravasation of blood into the pleural cavity. Image courtesy of Kaiser-Permanente.
