• Clinical science
  • Physician

Aortic dissection


An aortic dissection is a tear in the inner layer of the aorta which leads to a progressively growing hematoma between in the intima-media space. Hypertensive males between the 4th and 6th decade have the highest incidence of aortic dissection. Patients complain of a sudden onset and severe pain radiating into the thorax, back, or abdomen. Initial chest x-ray shows a widened mediastinum. The diagnosis is confirmed with a contrast-enhanced CT in stable patients and transesophageal echocardiography in unstable patients. Treatment options range from conservative measures (e.g., blood pressure optimization) to surgery (aortic prosthesis), depending on the localization and severity of the dissection. Complete occlusion of branching vessels and aortic rupture are common complications. Even with treatment, mortality rates associated with aortic dissection are high.



Epidemiological data refers to the US, unless otherwise specified.




Stanford classification

Stanford A = Affects ascending aorta; Stanford B = Begins beyond brachiocephalic vessels.



  • Anatomic site of origin
  • Transverse tear in the aortic intima (“entry”) → blood enters the media of the aorta and forms a false lumen in the intima-media space hematoma forms and propagates longitudinally downwards
    • → Rising pressure within the aortic wall → rupture
    • → Occlusion of every single branching vessel (e.g., coronary arteries, arteries supplying the brain, renal arteries, arteries supplying the lower limbs) → ischemia in the affected areas (see “Complications” below)
    • → A second intimal tear may result in a “reentry” into the primary aortic lumen.


Clinical features



  • Initial imaging: Chest x-ray (AP view) showing a widened mediastinum (> 8 cm)
  • Definitive diagnostic tests (determine the type of lumen, location, and extent of the dissecting membrane)
    • In stable patients → Contrast-enhanced CT angiography (gold standard) High sensitivity and specificity.
    • In unstable patients, renal insufficiency, contrast allergyTransesophageal echocardiography (TEE)
    • If contrast-enhanced CT is contraindicated in stable patients → Magnetic resonance angiography (MRA)
  • ECG: in all patients, although normal or signs of left ventricular hypertrophy


Differential diagnoses

The differential diagnoses listed here are not exhaustive.


Stanford A dissections; (involvement of the ascending aorta) require immediate surgery; , while Stanford B dissections are generally treated conservatively unless complications (e.g., rupture or occlusion) occur.

Conservative treatment


  • Open surgery with a polyester graft implantation
  • Possibly, endovascular treatment: aortic stent implantation (only in type B dissections and if the operative risk is too high)

Avoid thrombolytic therapy in patients with suspected aortic dissection!

Acute management checklist

All aortic dissection [10]

Ascending (type A) aortic dissection

  • Consult cardiothoracic surgery immediately.
  • Obtain preoperative labs (e.g., type and screen, CBC, coags, BMP, troponin).

Descending (type B) aortic dissection:

  • Consult cardiothoracic surgery for consideration of endovascular repair.

Ascending aortic dissection is a surgical emergency! Descending aortic dissection can often be managed medically.



We list the most important complications. The selection is not exhaustive.


  • In-hospital mortality due to aortic dissection ranges from 9 to 39%, depending on the type of dissection and treatment modality. [11][12]



  • Blood pressure control
  • Smoking cessation
  • Screening and repair of rapidly expanding aneurysms (also see “Therapy” and “Prevention” sections in aortic aneurysms)
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last updated 03/30/2020
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