Internal Diseases and Therapy · MU Sofia

38. Aortic diseases: aortic dissection, aortic aneurysm, Takayasu diseas

Covers acute aortic syndromes, starting with dissection: its definition, epidemiology, risk factors and pathogenesis, then the Stanford and DeBakey classifications with a timing scheme, the ADD-RS risk score and its diagnostic pathway, and the treatment split between type A surgery and type B care. It then turns to aortic aneurysms, comparing abdominal and thoracic sites, the causes, screening, and repair thresholds in a table, followed by Takayasu arteritis with its clinical phases, ACR criteria and immunosuppressive treatment.

Inside: 4 sections · 3 labelled pictures · 4 tables · 16 flashcards · 13 min

Topic 38 of 139 in the MU Sofia syllabus for Internal Diseases and Therapy (Medicine, Years 4 and 5). The free AceMed note covers it in 4 sections, about 1,676 words (13 min of reading), with 16 flashcards.

In this note

  1. Acute aortic syndromes
  2. Aortic dissection
  3. Aortic aneurysm
  4. Takayasu arteritis

Acute aortic syndromes

Acute aortic syndromes (AAS) are emergencies in which the aortic media is disrupted: classic dissection, intramural haematoma (IMH), penetrating atherosclerotic ulcer (PAU) and (contained) rupture. They present alike and are managed by location (ESC 2024 peripheral arterial and aortic diseases).

Aortic dissection

Definition

  • A tear in the intima lets blood into the media, which splits along its length: a false lumen separated from the true lumen by an intimal flap.
  • IMH: blood in the media without a visible intimal tear (bleeding vasa vasorum or a micro-tear); it can progress to dissection or rupture.
  • PAU: an atherosclerotic plaque that ulcerates through the internal elastic lamina into the media, mostly in the descending aorta of elderly patients.

Epidemiology and risk factors

  • About 4–6 per 100,000 per year; men about twice as often; peak 60–80 years (younger in genetic disease).
  • Hypertension is the main risk factor (about three quarters of patients).
  • Weak aortic wall: existing aneurysm, bicuspid aortic valve, coarctation; heritable disease: Marfan syndrome (FBN1), Loeys–Dietz syndrome, vascular Ehlers–Danlos syndrome, Turner syndrome, familial thoracic aortic disease.
  • Aortitis (giant cell arteritis, Takayasu arteritis, syphilis); cocaine and amphetamines; extreme straining (weightlifting); late pregnancy and the peripartum period; cardiac surgery or catheterisation; deceleration trauma.

Pathogenesis and consequences

  • Medial degeneration (loss of elastic fibres and smooth muscle) plus high wall stress → intimal tear, usually just above the aortic valve or just beyond the left subclavian artery → the false lumen extends forwards and/or backwards, often with re-entry tears.
  • Rupture: into the pericardium (haemopericardium, tamponade: the main cause of death in type A), the left pleura (haemothorax) or the mediastinum.
  • Backward extension to the root: acute aortic regurgitation; occlusion of a coronary ostium, usually the right coronary artery (inferior myocardial infarction).
  • Branch malperfusion (flap over an ostium or compressed true lumen): stroke (carotids), pulse loss (subclavian), paraplegia (spinal arteries), bowel ischaemia, acute kidney injury, leg ischaemia.

Classification

Image: “Disekce klasifikace DeBakey a Stanford” by Vanda Machová MD, CC BY 3.0, via Wikimedia Commons.

  • ESC 2024 also names "non-A non-B" dissection (arch involved, ascending spared) and the TEM system (Type, Entry tear, Malperfusion).
  • Timing: hyperacute < 24 h, acute 1–14 days, subacute 15–90 days, chronic > 90 days.
  • Complicated type B: rupture, malperfusion, pain or hypertension resistant to drugs, rapid expansion.

Clinical features

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