Acute aortic syndrome

Acute aortic syndrome
Major aorta anatomy displaying ascending aorta, brachiocephalic trunk, left common carotid artery, left subclavian artery, aortic isthmus, aortic arch, and descending thoracic aorta
Specialty	Vascular surgery

Acute aortic syndrome (AAS) describes a range of severe, painful, potentially life-threatening abnormalities of the aorta.[1] These include aortic dissection, intramural thrombus, and penetrating atherosclerotic aortic ulcer.[2] AAS can be caused by a lesion on the wall of the aorta that involves the tunica media, often in the descending aorta.[3] It is possible for AAS to lead to acute coronary syndrome.[4] The term was introduced in 2001.[5][6]

Signs and symptoms

The most common symptom of AAS is sudden and severe chest pain. However, other variants of chest pain and back pain have been described.[7]

Causes

Causes can include aortic dissection (which is the most common type),[8] intramural hematoma, penetrating atherosclerotic ulcer or a thoracic aneurysm that has become unstable.[9] The potential causes of AAS are life-threatening and present with similar symptoms, making it difficult to distinguish the ultimate cause, though high resolution, high contrast computerised tomography can be used.[9][10]

Diagnosis

The condition can be mimicked by a ruptured cyst of the pericardium,[11] ruptured aortic aneurysm[10] and acute coronary syndrome.[12]

Misdiagnosis is estimated at 39% and is associated with delays correct diagnosis and improper treatment with anticoagulants producing excessive bleeding and extended hospital stays.[12]

Management

AAS is life-threatening, with a high mortality rate if appearing acutely, reduced only when diagnosed early and treated by a surgeon with considerable expertise.[3] If patients survive acute presentation, within three to five years 30% will develop complications and require close follow-up.[3] Early diagnosis is essential for survival and management is challenging though greater awareness of the syndrome and improving management strategies are improving patient outcomes.[13]

References

1. Ahmad F, Cheshire N, Hamady M (May 2006). "Acute aortic syndrome: pathology and therapeutic strategies". Postgrad Med J. 82 (967): 305–12. doi:10.1136/pgmj.2005.043083. PMC 2563796. PMID 16679467.
2. Macura, KJ; Corl FM; Fishman EK; Bluemke DA (1 August 2003). "Pathogenesis in acute aortic syndromes: aortic dissection, intramural hematoma, and penetrating atherosclerotic aortic ulcer". American Journal of Roentgenology. 181 (2): 309–316. doi:10.2214/ajr.181.2.1810309. PMID 12876003.
3. Evangelista Masip A (April 2007). "[Progress in the acute aortic syndrome]". Revista Espanola de Cardiologia (in Spanish). 60 (4): 428–39. doi:10.1157/13101646. PMID 17521551.
4. Manghat NE, Morgan-Hughes GJ, Roobottom CA (December 2005). "Multi-detector row computed tomography: imaging in acute aortic syndrome". Clin Radiol. 60 (12): 1256–67. doi:10.1016/j.crad.2005.06.011. PMID 16291307.
5. van der Loo B, Jenni R (August 2003). "Acute aortic syndrome: proposal for a novel classification". Heart. 89 (8): 928. doi:10.1136/heart.89.8.928. PMC 1767786. PMID 12860875.
6. Vilacosta I, Román JA (April 2001). "Acute aortic syndrome". Heart. 85 (4): 365–8. doi:10.1136/heart.85.4.365. PMC 1729697. PMID 11250953.
7. Murphy, Michael C.; Castner, Catherine F.; Kouchoukos, Nicholas T. (2017). "Acute Aortic Syndromes: Diagnosis and Treatment". Missouri Medicine. 114 (6): 458–463. ISSN 0026-6620. PMC 6139964. PMID 30228665.
8. Gregory, Stephen H.; Yalamuri, Suraj M.; Bishawi, Muath; Swaminathan, Madhav (December 2018). "The Perioperative Management of Ascending Aortic Dissection". Anesthesia & Analgesia. 127 (6): 1302–1313. doi:10.1213/ANE.0000000000003747. ISSN 0003-2999. PMID 30211773. S2CID 52195386.
9. Smith AD, Schoenhagen P (January 2008). "CT imaging for acute aortic syndrome". Cleve Clin J Med. 75 (1): 7–9, 12, 15–7 passim. doi:10.3949/ccjm.75.1.7. PMID 18236724.
10. Marijon E, Vilanculos A, Tivane A, et al. (2007). "Thoracic aortic aneurysm: direct sign of rupture". Cardiovasc J Afr. 18 (3): 180–1. PMID 17612751.
11. Nishigami K, Hirayama T, Kamio T (February 2008). "Pericardial cyst rupture mimicking acute aortic syndrome". Eur. Heart J. 29 (14): 1752. doi:10.1093/eurheartj/ehn038. PMID 18296680.
12. Hansen MS, Nogareda GJ, Hutchison SJ (March 2007). "Frequency of and inappropriate treatment of misdiagnosis of acute aortic dissection". Am. J. Cardiol. 99 (6): 852–6. doi:10.1016/j.amjcard.2006.10.055. PMID 17350381.
13. Ince H, Nienaber CA (May 2007). "[Management of acute aortic syndromes]". Revista Española de Cardiología (English Edition) (in Spanish). 60 (5): 526–41. doi:10.1016/S1885-5857(07)60194-7. PMID 17535765.