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Aortic Dissection – Causes, Symptoms & Treatment

Aortic dissection is a life-threatening tear in the inner layer of the aorta, the body´s main artery. Immediate emergency medical care is essential for survival.

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Aortic dissection is a life-threatening tear in the inner layer of the aorta, the body´s main artery. Immediate emergency medical care is essential for survival.

What is Aortic Dissection?

Aortic dissection is a serious, life-threatening condition in which a tear occurs in the inner layer (intima) of the aorta – the largest artery in the human body. Blood forces its way through the tear and splits the layers of the aortic wall apart, creating a so-called false lumen. This false channel can rapidly extend along the aorta, compromising blood flow to vital organs. Aortic dissection is a medical emergency with a high mortality rate if not treated immediately.

Classification

Two widely used classification systems exist:

Stanford Classification: Type A involves the ascending aorta and typically requires emergency surgery. Type B is confined to the descending aorta and is usually managed medically first.
DeBakey Classification: Divides dissections into three types (I, II, III) based on the extent and location of the dissection along the aorta.

Causes and Risk Factors

The most common underlying cause is longstanding, poorly controlled arterial hypertension (high blood pressure), which weakens the aortic wall over time. Additional risk factors include:

Connective tissue disorders such as Marfan syndrome or Ehlers-Danlos syndrome
Pre-existing aortic conditions (e.g., aortic aneurysm, bicuspid aortic valve)
Atherosclerosis (hardening of the arteries)
Traumatic chest injuries
Stimulant drug use, particularly cocaine
Pregnancy (rare, typically in the third trimester)
Genetic predisposition and family history

Symptoms

The hallmark symptom of aortic dissection is a sudden, severe, tearing or ripping pain in the chest or back, often described as the worst pain the patient has ever experienced. A characteristic feature is the migratory nature of the pain: it can radiate to the back, abdomen, or legs as the dissection spreads. Other possible symptoms include:

Blood pressure difference between the two arms
Loss of consciousness or fainting
Stroke-like symptoms (e.g., weakness, speech difficulties)
Shortness of breath and cardiac arrhythmias
Absent or diminished pulse in an arm or leg
Shock symptoms (pallor, cold sweating, circulatory collapse)

Diagnosis

Diagnosis is typically confirmed through imaging studies. Key diagnostic methods include:

CT Angiography (CTA): Gold standard – provides fast and accurate visualization of the aorta and the extent of dissection
Transesophageal Echocardiography (TEE): Ultrasound via the esophagus, especially useful in unstable patients
MRI: Highly accurate, but more time-consuming and less suitable for emergency settings
Chest X-ray: May show a widened aorta but cannot rule out dissection
Blood tests: Elevated D-dimers may be present; troponin and other cardiac markers help with differential diagnosis

Treatment

Emergency Measures

If aortic dissection is suspected, emergency services must be called immediately. The patient is monitored in an intensive care unit, with stabilization of blood pressure and heart rate as priority goals.

Medical Management

The immediate goal is to rapidly lower blood pressure and heart rate to slow the progression of the dissection. Beta-blockers (e.g., esmolol, labetalol) and vasodilators (e.g., sodium nitroprusside) are the primary agents used.

Surgical Treatment

For Type A dissection (Stanford), emergency open surgery is usually required, replacing the affected aortic segment with a synthetic graft. For Type B dissection, conservative medical management is the first-line approach; however, in the presence of complications such as organ ischemia or rupture, a minimally invasive endovascular procedure (TEVAR – thoracic endovascular aortic repair) may be indicated.

Long-term Follow-up

Survivors of aortic dissection require regular imaging follow-up (e.g., MRI or CT scans) and lifelong blood pressure management to prevent recurrent dissections or late complications such as aneurysm formation.

References

Erbel R. et al. – 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases. European Heart Journal, 2014; 35(41): 2873–2926.
Nienaber CA, Clough RE. – Management of acute aortic dissection. The Lancet, 2015; 385(9970): 800–811.
Isselbacher EM et al. – 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease. Journal of the American College of Cardiology, 2022; 80(24): e223–e393.

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