Acute Aortic Dissection and Intramural Hematoma

A Systematic Review

Firas F. Mussa, Joshua D. Horton, Rameen Moridzadeh, Joseph Nicholson, Santi Trimarchi, Kim A. Eagle

Research output: Contribution to journalReview article

69 Citations (Scopus)

Abstract

IMPORTANCE: Acute aortic syndrome (AAS), a potentially fatal pathologic process within the aortic wall, should be suspected in patients presenting with severe thoracic pain and hypertension. AAS, including aortic dissection (approximately 90% of cases) and intramural hematoma, may be complicated by poor perfusion, aneurysm, or uncontrollable pain and hypertension. AAS is uncommon (approximately 3.5-6.0 per 100,000 patient-years) but rapid diagnosis is imperative as an emergency surgical procedure is frequently necessary.

OBJECTIVE: To systematically review the current evidence on diagnosis and treatment of AAS.

EVIDENCE REVIEW: Searches of MEDLINE, EMBASE, and the Cochrane Register of Controlled Trials for articles on diagnosis and treatment of AAS from June 1994 to January 29, 2016, were performed. Only clinical trials and prospective observational studies of 10 or more patients were included. Eighty-two studies (2 randomized clinical trials and 80 observational) describing 57,311 patients were reviewed.

FINDINGS: Chest or back pain was the most commonly reported presenting symptom of AAS (61.6%-84.8%). Patients were typically aged 60 to 70 years, male (50%-81%), and had hypertension (45%-100%). Sensitivities of computerized tomography and magnetic resonance imaging for diagnosis of AAS were 100% and 95% to 100%, respectively. Transesophageal echocardiography was 86% to 100% sensitive, whereas D-dimer was 51.7% to 100% sensitive and 32.8% to 89.2% specific among 6 studies (n = 876). An immediate open surgical procedure is needed for dissection of the ascending aorta, given the high mortality (26%-58%) and proximity to the aortic valve and great vessels (with potential for dissection complications such as tamponade). An RCT comparing endovascular surgical procedure to medical management for uncomplicated AAS in the descending aorta (n = 61) revealed no dissection-related deaths in either group. Endovascular surgical procedure was better than medical treatment (97% vs 43%, P < .001) for the primary end point of "favorable aortic remodeling" (false lumen thrombosis and no aortic dilation or rupture). The remaining evidence on therapies was observational, introducing significant selection bias.

CONCLUSIONS AND RELEVANCE: Because of the high mortality rate, AAS should be considered and diagnosed promptly in patients presenting with acute chest or back pain and high blood pressure. Computerized tomography, magnetic resonance imaging, and transesophageal echocardiography are reliable tools for diagnosing AAS. Available data suggest that open surgical repair is optimal for treating type A (ascending aorta) AAS, whereas thoracic endovascular aortic repair may be optimal for treating type B (descending aorta) AAS. However, evidence is limited by the paucity of randomized trials.

Original languageEnglish
Pages (from-to)754-763
Number of pages10
JournalJAMA - Journal of the American Medical Association
Volume316
Issue number7
DOIs
Publication statusPublished - Aug 16 2016

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Hematoma
Dissection
Chest Pain
Hypertension
Endovascular Procedures
Transesophageal Echocardiography
Back Pain
Thoracic Aorta
Aorta
Tomography
Magnetic Resonance Imaging
Mortality
Selection Bias
Acute Pain
Pathologic Processes
Therapeutics
Aortic Valve
MEDLINE
Observational Studies
Aneurysm

ASJC Scopus subject areas

  • Medicine(all)

Cite this

Mussa, F. F., Horton, J. D., Moridzadeh, R., Nicholson, J., Trimarchi, S., & Eagle, K. A. (2016). Acute Aortic Dissection and Intramural Hematoma: A Systematic Review. JAMA - Journal of the American Medical Association, 316(7), 754-763. https://doi.org/10.1001/jama.2016.10026

Acute Aortic Dissection and Intramural Hematoma : A Systematic Review. / Mussa, Firas F.; Horton, Joshua D.; Moridzadeh, Rameen; Nicholson, Joseph; Trimarchi, Santi; Eagle, Kim A.

In: JAMA - Journal of the American Medical Association, Vol. 316, No. 7, 16.08.2016, p. 754-763.

Research output: Contribution to journalReview article

Mussa, FF, Horton, JD, Moridzadeh, R, Nicholson, J, Trimarchi, S & Eagle, KA 2016, 'Acute Aortic Dissection and Intramural Hematoma: A Systematic Review', JAMA - Journal of the American Medical Association, vol. 316, no. 7, pp. 754-763. https://doi.org/10.1001/jama.2016.10026
Mussa, Firas F. ; Horton, Joshua D. ; Moridzadeh, Rameen ; Nicholson, Joseph ; Trimarchi, Santi ; Eagle, Kim A. / Acute Aortic Dissection and Intramural Hematoma : A Systematic Review. In: JAMA - Journal of the American Medical Association. 2016 ; Vol. 316, No. 7. pp. 754-763.
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N2 - IMPORTANCE: Acute aortic syndrome (AAS), a potentially fatal pathologic process within the aortic wall, should be suspected in patients presenting with severe thoracic pain and hypertension. AAS, including aortic dissection (approximately 90% of cases) and intramural hematoma, may be complicated by poor perfusion, aneurysm, or uncontrollable pain and hypertension. AAS is uncommon (approximately 3.5-6.0 per 100,000 patient-years) but rapid diagnosis is imperative as an emergency surgical procedure is frequently necessary.OBJECTIVE: To systematically review the current evidence on diagnosis and treatment of AAS.EVIDENCE REVIEW: Searches of MEDLINE, EMBASE, and the Cochrane Register of Controlled Trials for articles on diagnosis and treatment of AAS from June 1994 to January 29, 2016, were performed. Only clinical trials and prospective observational studies of 10 or more patients were included. Eighty-two studies (2 randomized clinical trials and 80 observational) describing 57,311 patients were reviewed.FINDINGS: Chest or back pain was the most commonly reported presenting symptom of AAS (61.6%-84.8%). Patients were typically aged 60 to 70 years, male (50%-81%), and had hypertension (45%-100%). Sensitivities of computerized tomography and magnetic resonance imaging for diagnosis of AAS were 100% and 95% to 100%, respectively. Transesophageal echocardiography was 86% to 100% sensitive, whereas D-dimer was 51.7% to 100% sensitive and 32.8% to 89.2% specific among 6 studies (n = 876). An immediate open surgical procedure is needed for dissection of the ascending aorta, given the high mortality (26%-58%) and proximity to the aortic valve and great vessels (with potential for dissection complications such as tamponade). An RCT comparing endovascular surgical procedure to medical management for uncomplicated AAS in the descending aorta (n = 61) revealed no dissection-related deaths in either group. Endovascular surgical procedure was better than medical treatment (97% vs 43%, P < .001) for the primary end point of "favorable aortic remodeling" (false lumen thrombosis and no aortic dilation or rupture). The remaining evidence on therapies was observational, introducing significant selection bias.CONCLUSIONS AND RELEVANCE: Because of the high mortality rate, AAS should be considered and diagnosed promptly in patients presenting with acute chest or back pain and high blood pressure. Computerized tomography, magnetic resonance imaging, and transesophageal echocardiography are reliable tools for diagnosing AAS. Available data suggest that open surgical repair is optimal for treating type A (ascending aorta) AAS, whereas thoracic endovascular aortic repair may be optimal for treating type B (descending aorta) AAS. However, evidence is limited by the paucity of randomized trials.

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