UMEM Educational Pearls

Title: Acute Aortic Syndromes

Keywords: Aortic Syndrome, Aortic Dissection, Intramural hematoma, Atheromatous ulcer (PubMed Search)

Posted: 10/6/2013 by Semhar Tewelde, MD
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Acute Aortic Syndromes

Classically, aortic dissection is considered the primary culprit in patients with chest pain that radiates to the back (aortic pain) or chest pain combined with ischemia (cerebral, cardiac, peripheral), syncope, or cardiac arrest. However, it should not be your only concern: the rate of aortic rupture is much higher in penetrating atheromatous ulcer (42%) and intramural hematoma (35%) than in aortic dissection (types A 7.5% and type B 4.1%).

Chest pain with concomitant ischemic symptoms and acute decompensation should prompt consideration of several etiologies under the umbrella of aortic syndromes and not limited to dissection :

Penetrating atheromatous ulcer - rupture of an atheromatous plaque through the internal elastic lamina, with subsequent localized medial disruption and potential dissection, pseudoaneurysm formation, or free rupture
Intramural hematoma - rupture of the vasa vasorum or hemorrhage within an atherosclerotic plaque followed by aortic wall infarct
Aortic dissection- an intimal tear with resultant propagation within the middle third of the medial layer of the aorta
Aneurysm leak or rupture - progressive vessel dilation and increased wall tension
Traumatic transection - rapid deceleration forces or direct trauma, commonly shearing distal to left subclavian artery at aortic isthmus where the aorta is fixed by ligamentum arteriosum

References

Sheikh A, Ali K, Mazhar S. Acute Aortic Syndrome. Circulation 2013;128:1122-1127

Coady MA, Rizzo JA, Elefteriades JA. Pathological Variants of thoracic aortic dissection. Penetrating atherosclerotic ulcers and intramural hematomas. Cardiol Clin. 1999;17:637-657