Aortic Dissection

Question 1

Aneurysm vs. Dissection

Answer 1

Weakening of all 3 layers vs. peeling apart b/w 2

Question 2

Vasa Vasorum & Dissection Plane

Answer 2

B/w middle and outer 1/3 of media

Question 3

5 Predisposing RFs for AD

Answer 3

HTN*
Cocaine
Pregnancy
Trauma
Cystic Medial Necrosis - Marfan's

Question 4

Primary vs. Secondary Intimal Tear

Answer 4

Initial punching through of intima vs. reentry of blood back into lumen. Better surivival

Question 5

2 Elements of Classification of AD

Answer 5

Duration: Acute (2 wks)

Anatomical Location - site of tear & extent of dissection

Question 6

3 DeBakey Classifications

Answer 6

I: primary tear asc->desc
II: just asc
III: just desc

Question 7

2 Stanford Classifications and Why (& treatment differential for each)

Answer 7

Doesn’t really matter where primary tear is, just if proximal is involved or not.
A: Proximal involved, surgical emergency (DeBakey I and II)
B: Proximal spared, medical treatment better (III)

Question 8

Isthmus

Answer 8

Only site where aorta fixed, so trauma can def cause dissection

Question 9

Most Likely Site of AD

Answer 9

1st 2 cm of asc aorta - bad because shitload of vessels and stuff there

Question 10

Problem w/ Very Proximal Intima Tear

Answer 10

Rupture goes into pericardium, which usually has very low pressure. So then pericardium gets LV pressure and get immediate hemmorhagic tamponade -> obstructive shock and death

Question 11

Major Cause(s) of Death in AD

Answer 11

Rupture or extension of dissecting hematoma

Question 12

2nd Most Likely Rupture Spot

Answer 12

Into pleural cavity

Question 13

How to Test for Retroperitoneal Rupture

Answer 13

Smack the CVA hard and it’ll hurt like my dick your ass Ronak

Question 14

1 Extension Site (& repercussions)

Answer 14

Brachiocephalic a. Unequal BP b/w R and L arm (R way lower)

Question 15

Most Common Re-Entry Point(s)

Answer 15

Common iliacs. Femoral bruits and shit

Question 16

Syncope

Answer 16

From tamponade, person already dead

Question 17

2 Mechs of Pulse Loss from Brachiocephalic (more common and more permanent)

Answer 17

Dissection extends up brachiocephalic and occludes - more permanent
Tear causes flap to transiently wall off a. - more common

Question 18

3 Mechs of Aortic Insufficiency

Answer 18

Symmetric hematoma causes pulling apart - easy to fix
Asymmetric hematoma pulls away 1 leaflet, still easy
Torn Valve - much more serious

Question 19

False Lumen Blood Supply

Answer 19

Limbs can be supplied by F lumens instead of T, and then repairing the dissection causes limb ischemia and amputation. So need to know what’s being perfused by F lumens

Question 20

3 Important PE Findings (& important point)

Answer 20

Ridiculous HTN (diastolic > 140)
Despite that, shocky appearance
Deficiency of pulse - unequal in arms
PE findings very variable so need to check very freq

Question 21

CXR Finding

Answer 21

Widened mediastinum

Question 22

3 Major Complications of Acute AD

Answer 22

Rupture
Extension
Acute AR - problem bc heart can’t handle acute stuff well

Question 23

AD Management (general)

Answer 23

Halt progression of dissecting hematoma - solve impulse (dP/dT) BEFORE BP (else can just make it worse)
Negative ionotropic agents. Dissection caused by pulsatile flow, so that increases w/ AL reduction so don’t reduce BP first. Reduce dP/dT w/ BBs**, then reduce SBP w/ vasodilators

Question 24

Combined Beta and Alpha Blocker, so impulse and SBP Reducer

Answer 24

Labetolol

Question 25

#1 Diagnostic Test for AD (& why)

Answer 25

TEE bc fast

Question 26

Surgical vs. Medical Management

Answer 26

Acute Prox Dissection, or distal if vital organ compromised or impending rupture or some other stuff vs. uncomplicated distal or stable arch, or stable chronic bc person already a survivor