A life-threatening emergency every doctor must recognise early.
Aortic dissection occurs when a tear in the inner layer of the aorta allows blood to enter the media, creating a false lumen. This weakens the vessel wall and may lead to rupture, malperfusion of vital organs, or death.
🚨 Sudden, severe tearing chest or back pain + pulse deficit = suspect aortic dissection
Step 1: Tear in the intimal layer
Step 2: Blood dissects through the media → false lumen forms
Step 3: Dissection may extend proximally or distally, leading to complications such as:
Coronary or branch vessel obstruction → ischaemia or stroke
Aortic rupture → tamponade or haemothorax
Aortic regurgitation (if dissection involves aortic root)
💡 Most tears originate in the ascending aorta within 2–3 cm of the aortic valve
| Classification | Location | Initial Management |
|---|---|---|
| Type A | Involves ascending aorta (± descending) | 🚨 Surgical emergency |
| Type B | Confined to descending aorta | Medical therapy ± endovascular repair |
🚨 All Type A dissections are considered surgical emergencies due to the high mortality risk
| Increased Risk | Protective Measures |
|---|---|
| Hypertension (most common) | Strict blood pressure control |
| Marfan's or Ehlers-Danlos syndromes | Genetic counselling, monitoring |
| Bicuspid aortic valve | Surveillance imaging |
| Aortic aneurysm, trauma, cocaine use | Risk modification |
| Pregnancy (especially 3rd trimester) | High-risk care pathways |
💡 Hypertension is the strongest modifiable risk factor
| Feature | Clues |
|---|---|
| Pain | Abrupt onset, tearing or ripping in nature |
| Radiation | Neck/jaw (Type A), back/interscapular (Type B) |
| Pulse/BP changes | Hypotension (rupture), Hypertension (Type B) |
| Neurology | Syncope, stroke, spinal cord ischaemia |
| Complications | Aortic regurgitation, tamponade, STEMI, mesenteric ischaemia |
🚨 Hypotension with chest/back pain may signal rupture or tamponade
| Test | Role |
|---|---|
| CT Aortogram | ✅ First-line: shows intimal flap, extent of dissection |
| ECG | May show non-specific changes or mimic STEMI |
| CXR | May reveal widened mediastinum |
| TOE | Used in unstable patients if CT not feasible |
| D-dimer | Elevated (>400 ng/mL) but not specific |
💡 Never delay CT aortogram for D-dimer or troponin if clinical suspicion is high
Type A Dissection (Ascending Aorta)
🚨 Requires emergency surgery — aortic graft repair ± valve replacement
Delayed treatment increases mortality by ~1% per hour
Type B Dissection (Descending Aorta)
✅ Initial management is medical unless complications arise
BP control (target SBP ~100–120 mmHg)
Pain management
Organ protection
Surgical or Endovascular Intervention (TEVAR) may be required if:
| Indication | Clue |
|---|---|
| Malperfusion | Abdominal pain, AKI, stroke |
| Ongoing pain | Despite treatment |
| Rupture/aneurysm | Haemodynamic instability |
| Resistant hypertension | Despite medical therapy |
💡 Most uncomplicated Type B dissections are managed medically
✅ Strict BP control (SBP <130/80 mmHg) — often lifelong beta-blocker
✅ Surveillance imaging with CT/MRI aortography:
At 3–6 months post-treatment
Then annually
Avoid heavy lifting and high-strain activities
Screen for further aortic dilation or recurrence
💡 Lifelong imaging follow-up is crucial due to risk of aneurysm and re-dissection
Fries Tips
🚨 Sudden tearing chest/back pain with pulse deficit = aortic dissection
Stanford Type A = Surgery, Type B = Medical unless complicated
CT Aortogram is gold standard for diagnosis
BP control is key — beta-blockers are first-line
Aortic regurgitation murmur = think proximal dissection
Never delay imaging for lab results in suspected dissection
