Aortic Dissection & Occlusion: Catastrophic Vascular Emergency

Aortic dissection (intimal tear → false lumen) or complete occlusion is a time-critical catastrophe.

Pathophysiology

• Intimal tear → blood enters media → false lumen propagation
• Stanford A (ascending involved) = surgical emergency
• Stanford B (descending only) = medical ± endovascular
• Occlusion: Flap obstructs true lumen → branch vessel ischemia

Clinical Presentation

• Pain: Sudden, severe, tearing, migratory (chest → back → abdomen)
• Pulse Deficits: Asymmetric radial, femoral, carotid
• Neurologic: Stroke (carotid), paraplegia (spinal artery), syncope
• Cardiac: AR (diastolic murmur), tamponade (Beck's triad), MI (coronary ostia)
• Mesenteric/Renal/Limb Ischemia: Abdominal pain, AKI, limb pallor/pulselessness

Diagnosis

• CT Angiography (gold standard, 100% sens/spec)
• TEE (bedside, if unstable)
• CXR: Widened mediastinum, pleural effusion
• ECG: Often normal or nonspecific

Management

Stanford A

• Emergent surgical repair (ascending ± arch ± valve)
• Target SBP 100–120 mmHg (IV beta-blocker first, then vasodilator)

Stanford B

• Medical: IV beta-blocker + vasodilator (nicardipine, clevidipine)
• TEVAR for complications (malperfusion, rupture, refractory pain, expansion)

Mortality

• Type A: 1–2%/hour untreated; 15–30% operative
• Type B: 10% medical; higher if complicated

Think dissection in any sudden severe chest/back pain. Image immediately.