एओर्तिक दिसेक्सन

एओर्तिक दिसेक्सन छगु मेदिकल इमर्जेन्सी ख। थ्व अवस्थाय् एओर्ताया छुं सतह बाया हि सतहतेगु दथुइ वनि। थ्व छगू मेदिकल इमर्जेन्सी ख। बांलाक्क उपचार याःसां थ्व अवस्थां याना मनु छकलं हे सी फु। दिसेक्सनं याना एओर्टा पूवंकः बाःसा (स्वंगु हे तहय् बायावंसा) छकलं यक्व हि बाहा वनी। एरोर्टिक दिसेक्सनं हि धों रप्चर (rupture) जुसा  ८०% मोर्टालिटी रेट दै नापं ५०% उसाँय् मदुपिं अस्पताल थ्यने न्ह्यः हे सी धुंकी। दिसेक्सन ६ से मि  थ्यंसा उसाँय् मदुमेसित आकस्मिक शल्यक्रिया यायेमा। थ्व शल्यक्रिया यायेत २० घौ तक्कया ई मा। उसाँय् मदुमेसियात वासः बिया ३न्हु तक्क कोमाय् तैगु या। 

म्हसीका
दक्वं आर्तरीय् थें एओर्टा स्वंगु तह जाना दयाच्वंगु दै। त्युनिका इन्तिमा हियागु बाहा नापं प्रत्यक्ष स्वापूय् दयाच्वनि। थ्व सतह आपा कथं इन्दोथेलियल सेलं देकातगु दै। मेगु तह त्युनिका मिदिया ख। थ्व दथुयागु सतह स्मूथ मसल व इलास्तिक तिस्युं देकी। दक्ले पिनेया तह त्युनिका एद्भेन्तिसिया ख। थ्व तह कनेक्तिभ तिस्यु नं देकी। 

एओर्तिक दिसेक्सनय् हि इन्तिमा तहं दुहां वया मिदियाय् थ्यनि। हियागु बाहां मिदियायात खुनाछ्वया अप्व हि मुंकिगु थाय् देकी। थन्यागु थाय् एओर्ताया हाकय् थी-थी हाकः तक्क दयाच्वने फु। थ्व कथं एओर्ताया हाकः बायावनेबिले नुगःया दिशाय्, नुगः विपरित दिशाय् वा निगु हे दिशाय् वने फु। इन्तिमाय् घा आपालं एओर्तिक भाल्भ स्वया १०० मि मि दुनेया दुरीय् दयाच्वनि। 

एओर्तिक दिसेक्सनया मू खतरा एओर्ता मुइगु ख। एओर्ता मुया तच्वगु हि बाहा वना मनु सी फु। 

बायेगु व्यवस्था
90px90px90pxPercentage60 %10-15 %25-30 % TypeDeBakey IDeBakey IIDeBakey IIIStanford AStanford B ProximalDistal Classification of aortic dissection

एओर्तिक दिसेक्सनया वर्णन यायेत थी-थी कथंया बायेज्या न्ह्यब्वगु खने दु। थन्यागु बायेज्याय् आपालं दिसेक्सनया एनाटोमी वा लक्षणया विकास जुया गुलि ई धुंका उसाँय् मदुम्ह अस्पताल थ्यन, उकिया आधारय् देकातःगु खने दु। 

दिबेकी बायेगु व्यवस्था
थ्व व्यवस्थाया नां सर्जन व एओर्तिक दिसेक्सन ल्वेमि माइकल इ दिबेकीया नामे तःगु ख। थ्व व्यवस्थाय् एओर्तिक दिसेक्सनया एनातोमिकल देस्क्रिप्सन बी। थ्व व्यवस्थाय् दिसेक्सनया वर्गीकरण वास्तविक इन्तिमल घाःया थाय् व दिसेक्सनया मात्राया आधारय् याइ (थाय्‌ एस्सेन्दिङ्ग एओर्ता, दिस्सेन्दिङ्ग एओर्ता वा निगु हे जुइफुDeBakey ME, Henly WS, Cooley DA, Morris GC Jr, Crawford ES, Beall AC Jr. Surgical management of dissecting aneurysms of the aorta. J Thorac Cardiovasc Surg 1965;49:130-49. PMID 14261867.)
प्रकार I - एस्सेक्दिङ्ग एओर्ताय् न्ह्यथनि, म्होय् नं एओर्तिक आर्क तक्क थ्यनि व आपालं आर्क स्वया नं तापाक्क वनि।
प्रकार II – एस्सेन्दिङ्ग एओर्ताय् न्ह्यथना थुकिलि हे सीमित जुइ। 
प्रकार III – दिस्सेन्दिङ्ग एओर्ताय् न्ह्यथना म्हो अवस्थाय् सत्तिकः वनि।

स्ट्यानफर्द बायेगु व्यवस्था
एस्सेन्दिङ्ग एओर्ता सम्बन्धित दु/मदुया आधारय् २ गु पुचले विभाजित यानातगु दु, क्रमशः A व B।Daily PO, Trueblood HW, Stinson EB, Wuerflein RD, Shumway NE. Management of acute aortic dissections. Ann Thorac Surg 1970;10:237-47. PMID 5458238.
A = प्रकार I व II दिबेकी
B = प्रकार III दिबेकी

प्याथोफिजियोलोजी
एओर्तिक दिसेक्सनया न्ह्यथनिगु झाका एओर्ताया इन्तिमा गुइगु ख। एओर्ताया उच्च रक्तचापं याना हि मिदियाय् गुयाच्वंगु थासं दुहां वनि। हि बाहां याना गुयावंगु घा झन तच्वया वनि। थ्व कथं तच्वना प्रोक्जिमल्ली (नुगः नापं) वा दिस्तल्ली (नुगः स्वया विपरित दिशाय् ) वा निगु हे दिशाय् वने फु। हि मिदियाय् दुहां वना स्युदोएन्युरिजम देकी। फल्स ल्युमेन व ट्रु ल्युमेनयात इन्तिमल तन्तुया छगू सतहं बाना तइ। थन्यागु तहयात इन्तिमल फ्ल्याप धाइ।

एओर्तिक दिसेक्सन आपा याना इन्तिमल टियरं न्ह्यथनि व थन्यागु टियर एसेन्दिङ्ग एओर्ता (६५%), एओर्तिक आर्क (१०%), वा दिसेन्दिङ्ग एओर्ताया लिगामेन्तम एओर्तिओसम् (२०%)य् आपालं खने दइ। 

हि फल्स ल्युमेनं बाहा वनेबिले बाहां इन्तिमाय् सेकेन्डरी टियर देके फु। थन्यागु सेकेन्दरी टियरं याना हि ल्युमेनय् हानं दुहां वने फु। 

इन्तिमल टियर छाय् जुइ धका बांलाक्क मस्युसां थुलि खं सी दु कि थन्यागु टियरय् मिदिया देकिगु कोल्याजेन व इल्यास्तिनया दिजेनेरेसन जुइ। थुकियात सिस्तिक मेदियल नेक्रोसिस धाइ व थन्यागु अवस्था आपालं मार्फान सिन्द्रम व एह्लर्स-दान्लोज सिन्द्रमय् खने दै।

थ्यं-मथ्यं १३% एओर्तिक दिसेक्सनय् इन्तिमल टियरया छुं निशान मलु। थन्यागु अवस्थाय् न्ह्यथनिगु कारक छगू इन्ट्राम्युरल हेमातोमा (मिदिया दुनेया हेमोरेजं याना) जुइगु धइगु विश्वास दु। थन्यागु अवस्थाय् ट्रु व फल्स ल्युमेनय् छुं नं स्पष्ट स्वापू मदइगुलिं थन्यागु अवस्थाय् एओर्तोग्राफी छ्य्‌ला डायग्नोज याये थाकु। इन्त्राम्युरल हेमातोमां याःगु एओर्तिक दिसेक्सनयात इन्तिमल टियरं याःगु एओर्तिक दिसेक्सनयात थें हे याना व्यवहार यायेमा।

कारक
एओर्तिक दिसेक्सन हाइपरतेन्सन व थी-थी कनेक्तिभ तन्तुया ल्वे नाप स्वापू दूगु ल्वे ख। थ्व ल्वे म्हो अवस्थाय् भास्कुलाइतिसनाप नं सम्बन्धित जु। नापं चेस्ट ट्रमाया लिच्वःया कथं नं थ्व ल्वे जुइफु। थ्व ल्वे दैपिं आपालं ल्वमिइ हाइपरतेन्सन दयाच्वनि।   

थ्व ल्वे दकले अप्व ५०दँ निसें ७०दँया मनुइ खनेदु। थ्व ल्वे मिसा स्वया मिजंय् निच्वः अप्व खनेदु (लैंगिक अनुपात मिजं:मिसा=२:१) । ४०दँ स्वया म्हो दँया मिसाय् थ्व ल्वे मचा प्वाथय् दइ बिले (३गु त्राइमेस्तर व पोस्तपार्तम ईले) खनेदु।

थ्व ल्वचं कापिं मनुइ ७-१४% तक्क मनुइ बाइकस्पिद एओर्तिक भाल्भ दयाच्वनि। These individuals are prone to dissection in the ascending aorta.  The risk of dissection in individuals with bicuspid aortic valve is not associated with the degree of stenosis of the valve.

मार्फान सिन्द्रम is noted in 5-9% of individuals who suffer from aortic dissection.  In this subset, there is an increased incidence in young individuals.  Individuals with Marfan syndrome tend to have aneurysms of the aorta and are more prone to proximal dissections of the aorta.

Turner syndrome also increases the risk of aortic dissection, by aortic root dilatationIncreased maternal cardiovascular mortality associated with pregnancy in women with Turner syndrome..

Chest trauma leading to aortic dissection can be divided into two groups based on etiology:  blunt chest trauma (commonly seen in car accidents) and iatrogenic.  Iatrogenic causes include trauma during cardiac catheterization or due to an intra-aortic balloon pump.

Aortic dissection may be a late sequalae of cardiac surgery.  18% of individuals who present with an acute aortic dissection have a history of open heart surgery.  Individuals who have undergone aortic valve replacement for aortic insufficiency are at particularly high risk.  This is because aortic insufficiency causes increased blood flow in the ascending aorta.  This can cause dilatation and weakening of the walls of the ascending aorta.

लक्षण
About 96% of individuals with aortic dissection present with severe pain that had a sudden onset.  It may be described as tearing in nature, or stabbing or sharp in character.  17% of individuals will feel the pain migrate as the dissection extends down the aorta.  The location of pain is associated with the location of the dissection.  Anterior chest pain is associated with dissections involving the ascending aorta, while intrascapular (back) pain is associated with descending aortic dissections.  If the pain is pleuritic in nature, it may suggest acute pericarditis due to hemorrhage into the pericardial sac.

While the pain may be confused with the pain of a myocardial infarction (heart attack), aortic dissection is usually not associated with the other signs that suggest myocardial infarction, including heart failure, and ECG changes.  Also, individuals suffering from an aortic dissection usually do not present with diaphoresis (profuse sweating).

Individuals with aortic dissection who do not present with pain have chronic dissection.

Less common symptoms that may be seen in the setting of aortic dissection include congestive heart failure (7%), syncope (9%), cerebrovascular accident (3-6%), ischemic peripheral neuropathy, paraplegia, cardiac arrest, and sudden death.  If the individual had a syncopal episode, about half the time it is due to hemorrhage into the pericardium leading to pericardial tamponade.

Neurologic complications of aortic dissection (i.e., cerebrovascular accident (CVA) and paralysis) are due to involvement of one or more arteries supplying portions of the central nervous system.

If the aortic dissection involves the abdominal aorta, compromise of the branches of the abdominal aorta are possible.  In abdominal aortic dissections, compromise of one or both renal arteries occurs in 5-8% of cases, while mesenteric ischemia (ischemia of the large intestines) occurs 3-5% of the time.

ब्लड प्रेसर भिन्नता
While many patients with an aortic dissection have a history of hypertension, the blood pressure is quite variable at presentation with acute aortic dissection, and tends to be higher in individuals with a distal dissection.  In individuals with a proximal aortic dissection, 36% present with hypertension, while 25% present with hypotension.  In those that present with distal aortic dissections, 70% present with hypertension while 4% present with hypotension.

Severe hypotension at presentation is a grave prognostic indicator.  It is usually associated with pericardial tamponade, severe aortic insufficiency, or rupture of the aorta.  Accurate measurement of the blood pressure is important.  Pseudohypotension (falsely low blood pressure measurement) may occur due to involvement of the brachiocephalic artery (supplying the right arm) or the left subclavian artery (supplying the left arm).

एओर्टिक इन्सफिसियन्सी
Aortic insufficiency (AI) occurs in 1/2 to 2/3 of ascending aortic dissections, and the murmur of aortic insufficiency is audible in about 32% of proximal dissections.  The intensity (loudness) of the murmur is dependent on the blood pressure and may be inaudible in the event of hypotension.

There are multiple etiologies for AI in the setting of ascending aortic dissection.  The dissection may dilate the annulus of the aortic valve, so that the leaflets of the valve cannot coapt.  Another mechanism is that the dissection may extend into the aortic root and detach the aortic valve leaflets.  The third mechanism is that if there was an extensive intimal tear, the intimal flap may prolapse into the LV outflow tract, causing intimal intussusception into the aortic valve preventing proper valve closure.

मायोकार्दियल इन्फार्क्सन
Myocardial infarction (heart attack) occurs in 1-2% of aortic dissections.  The etiology of the infarction is involvement of the coronary arteries (the arteries that supply the heart) in the dissection.  The right coronary artery is involved more commonly than the left coronary artery.  If the myocardial infarction is treated with thrombolytic therapy, the mortality increases to over 70%, mostly due to hemorrhage into the pericardial sac causing pericardial tamponade.

Because aortic dissection may present to the emergency room physician similar to a myocardial infarction, the physician must be careful to make the proper diagnosis prior to initiating treatment for myocardial infarction, since the treatment regimen for myocardial infarction can be lethal to an individual presenting with aortic dissection.

प्ल्युरल इफ्युजन
A pleural effusion (fluid collection in the space between the lungs and the chest wall or diaphragm) can be due to either blood from a transient rupture of the aorta or fluid due to an inflammatory reaction around the aorta. If a pleural effusion were to develop due to an aortic dissection, it is more commonly in the left hemithorax rather than the right hemithorax.

डायाग्नोसिस
Because of the varying symptoms and signs of aortic dissection depending on the initial intimal tear and the extent of the dissection, the proper diagnosis is sometimes difficult to make.

In an individual with chest pain radiating to the back, the differentials to consider include:
 Aortic dissection
 Myocardial infarction
 Acute aortic insufficiency
 Non-dissecting aortic aneurysm
 Pericarditis
 Musculoskeletal pain
 Mediastinal tumors

While taking a good history from the individual may be strongly suggestive of an aortic dissection, the diagnosis cannot always be made by history and physical signs alone.  Often the diagnosis is made by visualization of the intimal flap on a diagnositic imaging test.  Common tests used to diagnose an aortic dissection include a CAT scan of the chest with iodinated contrast material and a trans-esophageal echocardiogram.  Other tests that may be used include an aortogram or magnetic resonance angiogram (MRA) of the aorta.  Each of these test have varying pros and cons and they do not have equal sensitivities and specificities in the diagnosis of aortic dissection.

In general, the imaging technique chosen is based on the pre-test likelihood of the diagnosis, availability of the testing modality, patient stability, and the sensitivity and specificity of the test.

चेस्ट एक्स से
Widening of the mediastinum on an x-ray of the chest has moderate sensitivity (67%) in the setting of an ascending aortic dissection.  However, it has low specificity, as many other conditions can cause a widening of the mediastinum on chest x-ray.

The calcium sign is a finding on chest x-ray that suggests aortic dissection.  It is the separation of the intimal calcification from the outer aortic soft tissue border by 10 mm.

Pleural effusions may be seen on chest x-ray.  They are more commonly seen in descending aortic dissections.  If seen, they are typically in the left hemithorax.

Another findings are obliteration of the aortic knob, depression of the left mainstem bronchus, loss of the paratracheal stripe, and tracheal deviation.

About 12%-20% of individuals presenting with an aortic dissection have a "normal" chest x-ray.

इ सी जी
There are no specific electrocardiographic findings associated with aortic dissection.  About 1/3 of the time, the ECG will show signs of left ventricular hypertrophy, which is due to the long-standing hypertension seen in these individuals.  Another 1/3 of the time the ECG would be considered "normal".  If the ECG suggests cardiac ischemia in the setting 
of aortic dissection, involvement of the coronary arteries should be suspected.

बायोकेमिकल मार्कर
While there are currently no blood tests that can accurately diagnose aortic dissection, research has been performed into the serial measurement of monoclonal antibodies to smooth muscle myosin heavy chains that appears to be both sensitive and specific for aortic dissection.  The sensitivity of this test is about 90% and the specificity is 97% within the first 12 hours of the beginning of the dissection, and this assay can accurately differentiate myocardial infarction from aortic dissection.  This test is not currently available for the diagnosis of aortic dissection in the clinical setting.

ट्रान्सइसोफेजियल इकोकार्डियोग्राफी
The transesophageal echocardiogram (TEE) is a relatively good test in the diagnosis of aortic dissection, with a sensitivity of up to 98% and a specificity of up to 97%.  It is a relatively non-invasive test, requiring the individual to swallow the echocardiography probe.  It is especially good in the evaluation of AI in the setting of ascending aortic dissection, and to determine whether the ostia (origins) of the coronary arteries are involved.  While many institutions give sedation during transesophageal echocardiography for added patient-comfort, it can be performed in cooperative individuals without the use of sedation.  Disadvantages of the TEE include the inability to visualize the distal ascending aorta (the beginning of the aortic arch), and the descending abdominal aorta that lies below the stomach.  A TEE may be technically difficult to perform in individuals with esophageal strictures or varices.

एओर्टोग्राम
An aortogram involves placement of a catheter in the aorta and injection of contrast material while taking x-rays of the aorta. The procedure is known as aortography. The diagnosis of aortic dissection can be made by visualization of the intimal flap and flow of contrast material in both the true lumen and the false lumen.

The aortogram was previously considered the gold standard test for the diagnosis of aortic dissection, with a sensitivity of up to 88% and a specificity of about 94%.  It is especially poor in the diagnosis of cases where the dissection is due to hemorrhage within the media without any initiating intimal tear.

The advantage of the aortogram in the diagnosis of aortic dissection is that it can delineate the extent of involvement of the aorta and branch vessels and can diagnose aortic insufficiency.

The disadvantages of the aortogram are that it is an invasive procedure and it requires the use of iodinated contrast material.

कम्प्युतेद तोमोग्राफी एन्जियोग्राफी
180px180pxComputed tomography (CT) Legend Aortic dissection Type Stanford A1 Aorta ascendens, true Lumen - 2 false Lumen - 3 Pulmonary artery4 Aorta descendens - 5 thoracic vertebra
Computed tomography angiography is a fast non-invasive test that will give an accurate three-dimensional view of the aorta.  These images are produced by taking rapid thin cut slices of the chest and abdomen, and combining them in the computer to create cross-sectional slices.  In order to delineate the aorta to the accuracy necessary to make the proper diagnosis, an iodinated contrast material is injected into a peripheral vein. Contrast is injected and the scan performed using a Bolus Tracking method.  This is a type of scan timed to an injection, in order to capture the contrast as it enters the aorta.  The scan will then follow the contrast as it flows though the vessel.

It has a sensitivity of 96 - 100% and a specificity of 96 to 100%.  Disadvantages include the need for iodinated contrast material and the inability to diagnose the site of the intimal tear.

 एम आर आइ 
Magnetic resonance imaging (MRI) is currently the gold standard test for the detection and assessment of aortic dissection, with a sensitivity of 98% and a specificity of 98%.  An MRI examination of the aorta will produce a three-dimensional reconstruction of the aorta, allowing the physician to determine the location of the intimal tear, the involvement of branch vessels, and locate any secondary tears.  It is a non-invasive test, does not require the use of iodinated contrast material, and can detect and quantitate the degree of aortic insufficiency.

The disadvantage of the MRI scan in the face of aortic dissection is that it has limited availability and is often located only in the larger hospitals, and the scan is relatively time consuming.  Due to the high intensity of the magnetic waves used during MRI, an MRI scan is contraindicated in individuals with metallic implants.  In addition, many individuals experience claustrophobia while in the MRI scanning tube.

प्राकृतिक इतिहास
{| class="toccolours" align="right" cellpadding="4" cellspacing="0" style="margin: 0px 0px 1em 1em; clear:right;" 
|-
! colspan="3" bgcolor="#ccccff" align="center" | Risk of death in untreated aortic dissection
|-
| colspan="3" | 
|25% in first 24 hours
|50% in first week
|75% in first month
|90% in first year
|}

The risk of death is high in untreated aortic dissection.  While the risk is highest in the first 24 hours of the event, those that survive the initial event still have an elevated mortality compared to age- and sex-matched controls.

 First Aid and Pre-Hospital Life Support
It is unlikely that a lay-person will recognize this condition. Call for help and arrange for immediate transport via emergency medical services to advanced medical care. In wilderness first aid, immediate evacuation is imperative, by MEDEVAC to an advanced medical facility if available.

Transport immediately to a facility capable of emergency cardiac surgery such as a trauma center is suggested, not a community hospital without a surgical service.  Supportive care including pain and blood pressure control should be provided en route to the medical center.

For Basic Life Support Providers (EMT-B or equivalent): Treat for shock by placing the patient in a modified Trendelenburg position and administering oxygen therapy. Despite chest pain, do not administer nitrates.

For Advanced Life Support Providers (EMT-I or EMT-P): Initiate the above BLS steps. Apply cardiac monitoring and establish intravenous therapy early. Titrate fluid to blood pressure, but do not use vasopressors. Record a diagnostic electrocardiogram to distinguish between aortic dissection and acute myocardial infarction. Do not administer thrombolytics. Analgesia should be accomplished with regard to the vasodilative effects of opioid analgesics such as morphine, fentanyl, and nalbuphine and should not be provided to a patient in decompensated shock.

 Treatment 
The risk of death due to aortic dissection is highest in the first few hours after the dissection begins, and decreases afterwards.  Because of this, the therapeutic strategies differ for treatment of an acute dissection compared to a chronic dissection.  An acute dissection is one in which the individual presents within the first two weeks.  If the individual has managed to survive this window period, his prognosis is improved.  About 66% of all dissections present in the acute phase.

In all individuals with aortic dissections, medication should be used to control high blood pressure, if present.

In the case of an acute dissection, once diagnosis has been confirmed, the choice of treatment depends on the location of the dissection.  For ascending aortic dissection, surgical management is superior to medical management.  On the other hand, in the case of an uncomplicated distal aortic dissections (including abdominal aortic dissections), medical management is preferred over surgical treatment 

Individuals who present two weeks after the onset of the dissection are said to have chronic aortic dissections.  These individuals have been self-selected as survivors of the acute episode, and can be treated with medical therapy as long as they are stable.

Medical management is appropriate in individuals with an uncomplicated distal dissection, a stable dissection isolated to the aortic arch, and stable chronic dissections.  Patient selection for medical management is very important.  Stable individuals who present with an acute distal dissection (typically treated with medical management) still have an 8 percent 30 day mortality.

VIDEO - What is New in the Treatment of Type B Aortic Dissection?, Girma Tefera, MD, speaks at the University of Wisconsin School of Medicine and Public Health.

 Medical management 
The prime consideration in the medical management of aortic dissection is strict blood pressure control.  The target blood pressure should be a mean arterial pressure (MAP) of 60 to 75 mmHg.  Another factor is to reduce the shear-force dP/dt (force of ejection of blood from the left ventricle).

To reduce the shear stress, a vasodilator such as sodium nitroprusside should be used with a beta blocker, such as esmolol, propranolol, or labetalol.  The alpha-blocking properties of labetalol make it especially attractive in this situation.

Calcium channel blockers can be used in the treatment of aortic dissection, particularly if there is a contraindication to the use of beta blockers.  The calcium channel blockers typically used are verapamil and diltiazem, because of their combined vasodilator and negative inotropic effects.

If the individual has refractory hypertension (persistent hypertension on the maximum doses of three different classes of antihypertensive agents), involvement of the renal arteries in the aortic dissection plane should be considered.

 Surgical management 
Indications for the surgical treatment of aortic dissection include an acute proximal aortic dissection and an acute distal aortic dissection with one or more complications.  Complications include compromise of a vital organ, rupture or impending rupture of the aorta, retrograde dissection into the ascending aorta, and a history of Marfan's syndrome or Ehlers-Danlos Syndrome.

The objective in the surgical management of aortic dissection is to resect (remove) the most severely damaged segments of the aorta, and to obliterate the entry of blood into the false lumen (both at the initial intimal tear and any secondary tears along the vessel) ANN THORAC SURG, 1997; 64:1339-44 Tex Heart Inst J. 2002;29(1):56-9..  While excision of the intimal tear may be performed, it does not significantly change mortality.

Some methods of repair are:
 Replacement of the damaged section with a tube graft (often made of dacron) when there is no damage to the aortic valve.
 Bentall procedure - Replacement of the damaged section of aorta and replacement of the aortic valve.
 David procedure - Replacement of the damaged section of aorta and reimplantation of the aortic valve.
 Insertion of a stent, combined with on-going medical management

A number of comorbid conditions increase the surgical risk of repair of an aortic dissection.  These include:
 Prolonged pre-op evaluation (increased length of time prior to surgery)
 Advanced age
 Comorbid disease states (e.g.: coronary artery disease)
 Aneurysm leakage
 Cardiac tamponade
 Shock
 Past history of myocardial infarction or CVA
 History of renal failure (either acute or chronic renal failure)

 Long term follow-up 
The long term follow-up in individuals who survive aortic dissection involves strict blood pressure control.  The relative risk of late rupture of an aortic aneurysm is 10 times higher in individuals who have uncontrolled hypertension, compared to individuals with a systolic pressure below 130 mmHg.

The risk of death is highest in the first two years after the acute event, and individuals should be followed closely during this time period.  29% of late deaths following surgery are due to rupture of either the dissecting aneurysm or another aneurysm.  In addition, there is a 17% to 25% incidence of new aneurysm formation.  This is typically due to dilatation of the residual false lumen.  These new aneurysms are more likely to rupture, due to their thinner walls.

Serial imaging of the aorta is suggested, with MRI being the preferred imaging technique.

Famous victims
Deaths
King George II of Great Britain
Liese Prokop, Austrian Interior Minister and Olympic silver medallist
Lucille Ball, actress and entertainer
Flo Hyman, volleyball player
Jonathan Larson, composer of Rent
John Ritter, actor
Richard Biggs, actor
Mike Wieringo, American comic book artist
Jim Murray, American Sportswriter Los Angeles Times 1961-1998

Survivors
Dr. Michael E. DeBakey, who devised the surgery to correct aortic dissection (as well as other cardiovascular and vascular techniques).  Dr. DeBakey was also noteworthy for being the oldest patient ever to receive his own operation: he was 97 at the time of his surgery on February 9 and 10 of 2006.  He survived and, though he worked with physical therapists to walk on his own again after suffering muscle deconditioning from prolonged physical inactivity during recovery, retained all of his mental faculties and was back to working nearly a full day until his death of natural causes on July 11, 2008. (See  published 25 December, 2006, in the New York Times).
Daniel Dennett, philosopher
Gérard Houllier, former manager of Liverpool Football Club, now manages Olympic Lyonnais
Jose Miguel Arroyo, spouse of Philippine President Gloria Macapagal-Arroyo

See also
Aortic aneurysm
Connective tissue disease
Ehlers-Danlos Syndrome
Hypertension
Marfan syndrome
Traumatic aortic rupture
Bicuspid aortic valve

References

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