Acute Aortic Syndrome Revisited

Vilacosta I, San Román JA, di Bartolomeo R, et al.
Acute Aortic Syndrome Revisited: JACC State-of-the-Art Review. J Am Coll Cardiol 2021;78:2106-2125.

The following are key points to remember from this state-of-the-art review on acute aortic syndrome (AAS):

  1. AAS encompasses four conditions. (1) In classic dissection (CD), an intimal tear occurs and results in the creation and propagation of a false lumen. (2) In incomplete dissection, the intima and subjacent media are lacerated and a localized wall bulge and/or hematoma forms, without an associated false lumen. (3) In intramural hematoma (IMH), vasa vasorum rupture produces an intramural hemorrhage. IMH can be spontaneously reabsorbed or convert to CD. (4) In penetrating atherosclerotic ulcer, an ulcerating plaque penetrates the internal elastic lamina and disrupts the media. AAS lesions may appear simultaneously in different aortic segments, or sequentially.
  2. Any of the above pathologic conditions may progress to aortic rupture, especially within the first week. Approximately 30-50% of patients with Stanford type A CD (involving the ascending aorta) die before reaching the hospital.
  3. The incidence of AAS is nearly twofold higher in men than in women. Women with AAS are typically older and have higher mortality, including prehospital mortality.
  4. Centralizing care for AAD in high-volume aorta centers, with multidisciplinary aortic teams and focused expertise in aortic surgery, can reduce early mortality, limit reoperations, and improve long-term outcomes.
  5. The “aorta code” is a streamlined emergency care pathway that should be activated from the emergency department of small hospitals. Goals are threefold: increase awareness of AAS among emergency clinicians to facilitate early diagnosis, ensure swift patient transfer to aorta center, and provide optimal treatment by activation of the aorta team, including cardiologists, cardiovascular imaging specialists, cardiac and vascular surgeons, vascular interventional radiologists, and anesthesiologists.
  6. The authors propose a three-step algorithm to identify most patients with AAS: (1) calculate pretest probability based on risk factors, symptoms, and physical exam; (2) perform basic diagnostic evaluation including electrocardiography, chest X-ray, and biomarkers (troponin, which may or may not be elevated in AAS, and D-dimer, which is highly sensitive for AAS); and (3) computed tomography (CT) of the entire aorta with and without contrast, as well as transthoracic echocardiography (low sensitivity for AAS but important to assess for AAS complications including aortic regurgitation, pericardial effusion, and left ventricular dysfunction). Transesophageal echocardiography may be performed when CT is unavailable or nondiagnostic but is not routinely recommended, especially for unstable patients.
  7. Type A AAS is generally considered a surgical emergency. However, in type A IMH, an initial conservative approach may be appropriate for a hemodynamically stable patient with aortic diameter <50 mm and no ulcer-like projections. The extent and nature of the operation for type A AAS (for instance, total arch vs. hemiarch replacement) should be tailored based on surgeon and center experience and the patient’s clinical profile.
  8. For complicated type B CD, thoracic endovascular aortic repair (TEVAR), in addition to optimal medical therapy including strict blood pressure control, is the treatment of choice. High-risk features in type B CD include total aortic diameter >44 mm, false lumen diameter >22 mm, large proximal entrance tear, refractory pain, and refractory hypotension.
  9. Important measures for preventing AAS include identification of at-risk patients (including those with connective tissue disorders and familial aortic syndromes), control of hypertension, avoidance of fluoroquinolones (which have been associated with aortic aneurysm and CD in population-based studies), and surgical repair of aortic aneurysms. Current criteria for surgical aneurysm repair need refinement, as many type A CDs occur in patients with aortic diameters below the typical size threshold for intervention (55 mm).

Clinical Topics: Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Pericardial Disease, Prevention, Valvular Heart Disease, Vascular Medicine, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Heart Failure and Cardiac Biomarkers, Interventions and Imaging, Interventions and Structural Heart Disease, Interventions and Vascular Medicine, Computed Tomography, Echocardiography/Ultrasound, Nuclear Imaging, Hypertension

Keywords: Aortic Aneurysm, Aortic Rupture, Aortic Valve Insufficiency, Biomarkers, Cardiac Surgical Procedures, Diagnostic Imaging, Dissection, Echocardiography, Hematoma, Hypertension, Pericardial Effusion, Physical Examination, Primary Prevention, Tomography, X-Ray Computed, Ulcer, Vascular Diseases, Ventricular Dysfunction, Left

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