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November 21, 1990, Vol 264, No. 19 >
ARTICLE | November 21, 1990

The Diagnosis and Management of Aortic Dissection FREE

E. Stanley Crawford, MD
[+] Author Affiliations

This article is one of a series sponsored by the American Heart Association.

Reprint requests to Department of Surgery, Baylor College of Medicine and The Methodist Hospital, 6535 Fannin St, MS B-405, Houston, TX 77030 (Dr Crawford)


JAMA. 1990;264(19):2537-2541. doi:10.1001/jama.1990.03450190069031
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References

Aortic dissection is a severe disease. Most untreated patients with types I and II (proximal) dissection and over half of those with type III (distal) dissection die within 1 year. Most of the deaths occur within 2 weeks and are caused by rupture, aortic insufficiency, and branch vessel obstruction. Aortic dissection is suspected in patients with anterior chest and back pain that progresses downward. Diagnosis is confirmed by computed tomography, aortography, or echocardiography. Appropriate medical treatment and corrective surgery, including total aortic replacement, performed in the acute and chronic stages, are now successful in over 90% of the cases; long-term results of treatment are steadily improving and are expected to exceed 50% at 10 years. The keys to a successful outcome are being aware of the symptoms of dissection, early diagnosis, and prompt application of appropriate treatment; diligent follow-up includes controlling blood pressure, decreasing the velocity of left ventricular contraction, monitoring the size of the residual aorta, and taking appropriate action if redissection, aneurysmal formation, or rupture occurs.

(JAMA. 1990;264:2537-2541)

REFERENCES

1 +
Crawford ES, Svensson LG, Coselli JS, Safi HJ, Hess KR.  Aortic dissection and dissecting aortic aneurysms . Ann Surg. 1988;;208:254-273.
2 +
DeSanctis RW, Doroghazi RM, Austen WG, Buckley MJ.  Aortic dissection . N Engl J Med. 1987;:317:1060-1067.
3 +
White RD, Lipton MJ, Higgins CB, et al.  Noninvasive evaluation of suspected thoracic aortic disease by contrast-enhanced computed tomography . Am J Cardiol. 1986;:57:282-290.
4 +
Amparo EG, Higgins CB, Hricak H, Sollitto R.  Aortic dissection: magnetic resonance imaging . Radiology. 1985;;155:399-406.
5 +
Crawford ES, Coselli JS, Safi HJ.  Treatment dissection of ascending aorta and aortic arch based upon a study of patients requiring reoperation . Contemp Surg. 1986;;29:13-31.
6 +
Crawford ES, Crawford JL, Stowe CL, Safi HJ.  Total aortic replacement for chronic aortic dissection occurring in patients with and without Marfan's syndrome . Ann Surg. 1984;;199:358-362.
7 +
Crawford ES, Svensson LG, Coselli JS, Safi HJ, Hess KR.  Surgical treatment of aneurysm and/or dissection of the ascending aorta, transverse aortic arch, and ascending aorta and transverse aortic arch: factors influencing survival in 717 patients . J Thorac Cardiovasc Surg. 1989;;98:659-674.
8 +
Svensson LG, Crawford ES, Coselli JS, Safi HJ, Hess KR.  Impact of cardiovascular operation on survival in the Marfan patient . Circulation. 1989;;80( (suppl I) ):I-233—I-242.
9 +
Miller DC.  Surgical management of aortic dissections: indications, perioperative management, and long-term results . In: Doroghazi RM, Slater EE, eds: Aortic Dissection . New York, NY: McGraw-Hill International Book Co; 1983;:193-243.
10 +
Hashimoto S, Kumada T, Osakada G, et al.  Assessment of transesophageal Doppler echography in dissecting aortic aneurysm . J Am Coll Cardiol. 1989;;14:1253-1262.
11 +
Ergin MA, Galla JD, Lansman S, Griepp RB.  Acute dissection of the aorta: current surgical treatment . Surg Clin North Am. 1985;;65:721-741.
12 +
Kouchoukos NT, Marshall WG Jr, Wedige-Stecher TA.  Eleven-year experience with composite graft replacement of the ascending aorta and aortic valve . J Thorac Cardiovasc Surg. 1986;; 92:691-705.
13 +
Gott VL, Pyeritz RE, Magovern GJ Jr, Cameron DE, KcKusich VA.  Surgical treatment of aneurysms of the ascending aorta in the Marfan syndrome . N Engl J Med. 1986;;314:1070-1074.
14 +
Cabrol C, Pavie A, Mesnildrey P, et al.  Long-term results with total replacement of the ascending aorta and reimplantation of the coronary arteries . J Thorac Cardiovasc Surg. 1986;;91:17-25.
15 +
Haverich A, Miller DC, Scott WC, et al.  Acute and chronic aortic dissections: determinants of long-term outcome for operative survivors . Circulation. 1985;;72( (suppl II) ):II-22—II-34.
16 +
Galloway AC, Colvin SB, LaMendola CL, Hurwitz JB, et al.  Ten-year operative experience with 165 aneurysms of the ascending aorta and aortic arch . Circulation. 1989;;80( (suppl I) ):I-249—I-256.
17 +
Svensson LG, Crawford ES, Hess KR, et al.  Dissection of the aorta and dissecting aortic aneurysms: improving early and long-term surgical results . Circulation. 1990;;82( (suppl IV) ):IV-24—IV-38.
18 +
Crawford ES, Coselli JS, Svensson LG, Safi HJ, Hess KR.  Diffuse aneurysmal disease (chronic aortic dissection, Marfan, and mega-aorta syndromes) and multiple aneurysm: treatment by subtotal and total aortic replacement emphasizing the elephant trunk technique . Ann Surg. 1990;;211:521-537.
19 +
Hirst AE Jr, Johns VJ Jr, Kime SW Jr.  Dissecting aneurysm of the aorta: a review of 505 cases . Medicine (Baltimore). 1985;;37:217-279.
20 +
DeBakey ME, Henley WS, Cooley DA, Morris GG Jr, Crawford ES, Beall AC Jr.  Surgical management of dissecting aneurysms of the aorta . J Thorac Cardiovasc Surg. 1965;;49:130-149.
21 +
DeBakey ME, McCollum CH, Crawford ES, et al.  Dissection and dissecting aneurysms of the aorta: twenty-year follow-up of five hundred twenty-seven patients treated surgically . Surgery. 1982;; 92:1118-1134.
22 +
Daily PO, Trueblood W, Stinson EB, Wuerflein RD, Shumway NE.  Management of acute aortic dissections . Ann Thorac Surg. 1970;:10:237-247.
23 +
Roberts WC.  Aortic dissection: anatomy, consequences, and causes . Am Heart J. 1981;;101:195-214.
24 +
Crawford ES, Crawford JL. Diseases of the Aorta Including an Atlas of Angiographic Pathology and Surgical Technique . Williams & Wilkins; Baltimore, Md; 1984;.
25 +
Sarris GE, Miller DC.  Peripheral vascular manifestations of acute aortic dissection . In: Rutherford RB. Vascular Surgery . 3rd ed. Philadelphia, Pa: WB Saunders Co; 1989;:942-951.
26 +
Doroghazi RM, Slater EE, DeSanctis RW, Buckley MJ, Austen WG, Rosenthal S.  Long-term survival of patients with treated aortic dissection . J Am Coll Cardiol. 1984;;3:1026-1034.
27 +
Lindsay J Jr, Hurst JW.  Clinical features and prognosis in dissecting aneurysm of the aorta: a reappraisal . Circulation. 1967;;35:880-888.
28 +
Applebaum A, Karp RB, Kirklin JW.  Ascending vs descending aortic dissections . Ann Surg. 1976;;183:296-300.
29 +
Crawford ES, Crawford JL, Safi HJ, Coselli JS.  Redo operations for recurrent aneurysmal disease of the ascending aorta and transverse aortic arch . Ann Thorac Surg. 1985;;40:439-455.
30 +
Wheat MW Jr.  Intensive drug therapy . In: Doroghazi RM, Slater EE, eds. Aortic Dissection . New York, NY: McGraw-Hill International Book Co; 1983;:165-192.
31 +
Wheat MW Jr, Harris PD, Malm JR, et al.  Acute dissecting aneurysms of the aorta . J Thorac Cardiovasc Surg. 1969;;58:344-351.
32 +
Price WH, Wilson J.  Dissection of the aorta in Turner's syndrome . J Med Genet. 1983;;20:61-63.
33 +
Murphy DA, Craver JM, Jones EL, Bone DK, Guyton RA, Hatcher CR Jr.  Recognition and management of ascending aortic dissection complicating cardiac surgical operations . J Thorac Cardiovasc Surg. 1983;;85:247-256.
34 +
Muna WF, Spray TL, Morrow AG, Roberts WC.  Aortic dissection after aortic valve replacement in patients with valvular aortic stenosis . J Thorac Cardiovasc Surg. 1977;;74:65-69.
35 +
Coselli JS, Crawford ES.  Composite valve-graft replacement of aortic root using separate Dacron tube for coronary artery reattachment . Ann Thorac Surg. 1989;;47:558-565.
36 +
Glower DD, Fann JI, Speier RH, et al.  Comparison of medical and surgical therapy for uncomplicated descending aortic dissection . Circulation. 1990;;82( (suppl IV) ):IV-39-IV-46.
37 +
Crawford ES, Crawford JL, Safi HJ, Coselli JS, et al.  Thoraco-abdominal aortic aneurysms: preoperative and intraoperative factors determining immediate and long-term results of operations in 605 patients . J Vasc Surg. 1986;;3:578-582.

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1 +
Crawford ES, Svensson LG, Coselli JS, Safi HJ, Hess KR.  Aortic dissection and dissecting aortic aneurysms . Ann Surg. 1988;;208:254-273.
2 +
DeSanctis RW, Doroghazi RM, Austen WG, Buckley MJ.  Aortic dissection . N Engl J Med. 1987;:317:1060-1067.
3 +
White RD, Lipton MJ, Higgins CB, et al.  Noninvasive evaluation of suspected thoracic aortic disease by contrast-enhanced computed tomography . Am J Cardiol. 1986;:57:282-290.
4 +
Amparo EG, Higgins CB, Hricak H, Sollitto R.  Aortic dissection: magnetic resonance imaging . Radiology. 1985;;155:399-406.
5 +
Crawford ES, Coselli JS, Safi HJ.  Treatment dissection of ascending aorta and aortic arch based upon a study of patients requiring reoperation . Contemp Surg. 1986;;29:13-31.
6 +
Crawford ES, Crawford JL, Stowe CL, Safi HJ.  Total aortic replacement for chronic aortic dissection occurring in patients with and without Marfan's syndrome . Ann Surg. 1984;;199:358-362.
7 +
Crawford ES, Svensson LG, Coselli JS, Safi HJ, Hess KR.  Surgical treatment of aneurysm and/or dissection of the ascending aorta, transverse aortic arch, and ascending aorta and transverse aortic arch: factors influencing survival in 717 patients . J Thorac Cardiovasc Surg. 1989;;98:659-674.
8 +
Svensson LG, Crawford ES, Coselli JS, Safi HJ, Hess KR.  Impact of cardiovascular operation on survival in the Marfan patient . Circulation. 1989;;80( (suppl I) ):I-233—I-242.
9 +
Miller DC.  Surgical management of aortic dissections: indications, perioperative management, and long-term results . In: Doroghazi RM, Slater EE, eds: Aortic Dissection . New York, NY: McGraw-Hill International Book Co; 1983;:193-243.
10 +
Hashimoto S, Kumada T, Osakada G, et al.  Assessment of transesophageal Doppler echography in dissecting aortic aneurysm . J Am Coll Cardiol. 1989;;14:1253-1262.
11 +
Ergin MA, Galla JD, Lansman S, Griepp RB.  Acute dissection of the aorta: current surgical treatment . Surg Clin North Am. 1985;;65:721-741.
12 +
Kouchoukos NT, Marshall WG Jr, Wedige-Stecher TA.  Eleven-year experience with composite graft replacement of the ascending aorta and aortic valve . J Thorac Cardiovasc Surg. 1986;; 92:691-705.
13 +
Gott VL, Pyeritz RE, Magovern GJ Jr, Cameron DE, KcKusich VA.  Surgical treatment of aneurysms of the ascending aorta in the Marfan syndrome . N Engl J Med. 1986;;314:1070-1074.
14 +
Cabrol C, Pavie A, Mesnildrey P, et al.  Long-term results with total replacement of the ascending aorta and reimplantation of the coronary arteries . J Thorac Cardiovasc Surg. 1986;;91:17-25.
15 +
Haverich A, Miller DC, Scott WC, et al.  Acute and chronic aortic dissections: determinants of long-term outcome for operative survivors . Circulation. 1985;;72( (suppl II) ):II-22—II-34.
16 +
Galloway AC, Colvin SB, LaMendola CL, Hurwitz JB, et al.  Ten-year operative experience with 165 aneurysms of the ascending aorta and aortic arch . Circulation. 1989;;80( (suppl I) ):I-249—I-256.
17 +
Svensson LG, Crawford ES, Hess KR, et al.  Dissection of the aorta and dissecting aortic aneurysms: improving early and long-term surgical results . Circulation. 1990;;82( (suppl IV) ):IV-24—IV-38.
18 +
Crawford ES, Coselli JS, Svensson LG, Safi HJ, Hess KR.  Diffuse aneurysmal disease (chronic aortic dissection, Marfan, and mega-aorta syndromes) and multiple aneurysm: treatment by subtotal and total aortic replacement emphasizing the elephant trunk technique . Ann Surg. 1990;;211:521-537.
19 +
Hirst AE Jr, Johns VJ Jr, Kime SW Jr.  Dissecting aneurysm of the aorta: a review of 505 cases . Medicine (Baltimore). 1985;;37:217-279.
20 +
DeBakey ME, Henley WS, Cooley DA, Morris GG Jr, Crawford ES, Beall AC Jr.  Surgical management of dissecting aneurysms of the aorta . J Thorac Cardiovasc Surg. 1965;;49:130-149.
21 +
DeBakey ME, McCollum CH, Crawford ES, et al.  Dissection and dissecting aneurysms of the aorta: twenty-year follow-up of five hundred twenty-seven patients treated surgically . Surgery. 1982;; 92:1118-1134.
22 +
Daily PO, Trueblood W, Stinson EB, Wuerflein RD, Shumway NE.  Management of acute aortic dissections . Ann Thorac Surg. 1970;:10:237-247.
23 +
Roberts WC.  Aortic dissection: anatomy, consequences, and causes . Am Heart J. 1981;;101:195-214.
24 +
Crawford ES, Crawford JL. Diseases of the Aorta Including an Atlas of Angiographic Pathology and Surgical Technique . Williams & Wilkins; Baltimore, Md; 1984;.
25 +
Sarris GE, Miller DC.  Peripheral vascular manifestations of acute aortic dissection . In: Rutherford RB. Vascular Surgery . 3rd ed. Philadelphia, Pa: WB Saunders Co; 1989;:942-951.
26 +
Doroghazi RM, Slater EE, DeSanctis RW, Buckley MJ, Austen WG, Rosenthal S.  Long-term survival of patients with treated aortic dissection . J Am Coll Cardiol. 1984;;3:1026-1034.
27 +
Lindsay J Jr, Hurst JW.  Clinical features and prognosis in dissecting aneurysm of the aorta: a reappraisal . Circulation. 1967;;35:880-888.
28 +
Applebaum A, Karp RB, Kirklin JW.  Ascending vs descending aortic dissections . Ann Surg. 1976;;183:296-300.
29 +
Crawford ES, Crawford JL, Safi HJ, Coselli JS.  Redo operations for recurrent aneurysmal disease of the ascending aorta and transverse aortic arch . Ann Thorac Surg. 1985;;40:439-455.
30 +
Wheat MW Jr.  Intensive drug therapy . In: Doroghazi RM, Slater EE, eds. Aortic Dissection . New York, NY: McGraw-Hill International Book Co; 1983;:165-192.
31 +
Wheat MW Jr, Harris PD, Malm JR, et al.  Acute dissecting aneurysms of the aorta . J Thorac Cardiovasc Surg. 1969;;58:344-351.
32 +
Price WH, Wilson J.  Dissection of the aorta in Turner's syndrome . J Med Genet. 1983;;20:61-63.
33 +
Murphy DA, Craver JM, Jones EL, Bone DK, Guyton RA, Hatcher CR Jr.  Recognition and management of ascending aortic dissection complicating cardiac surgical operations . J Thorac Cardiovasc Surg. 1983;;85:247-256.
34 +
Muna WF, Spray TL, Morrow AG, Roberts WC.  Aortic dissection after aortic valve replacement in patients with valvular aortic stenosis . J Thorac Cardiovasc Surg. 1977;;74:65-69.
35 +
Coselli JS, Crawford ES.  Composite valve-graft replacement of aortic root using separate Dacron tube for coronary artery reattachment . Ann Thorac Surg. 1989;;47:558-565.
36 +
Glower DD, Fann JI, Speier RH, et al.  Comparison of medical and surgical therapy for uncomplicated descending aortic dissection . Circulation. 1990;;82( (suppl IV) ):IV-39-IV-46.
37 +
Crawford ES, Crawford JL, Safi HJ, Coselli JS, et al.  Thoraco-abdominal aortic aneurysms: preoperative and intraoperative factors determining immediate and long-term results of operations in 605 patients . J Vasc Surg. 1986;;3:578-582.

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