Management of acute aortic syndromes

Abstract

Acute aortic syndrome (AAS) is a modern term to describe interrelated emergency aortic conditions with similar clinical characteristics and challenges. These conditions include aortic dissection, intramural haematoma (IMH), and penetrating atherosclerotic ulcer (PAU and aortic rupture); trauma to the aorta with intimal laceration may also be considered. The common denominator of AAS is disruption of the media layer of the aorta with bleeding within IMH, along the aortic media resulting in separation of the layers of the aorta (dissection), or transmurally through the wall in the case of ruptured PAU or trauma. Population-based studies suggest that the incidence of acute dissection ranges from 2 to 3.5 cases per 100 000 person-years; hypertension and a variety of genetic disorders with altered connective tissues are the most prevalent risk conditions. Patients with AAS often present in a similar fashion, regardless of the underlying condition of dissection, IMH, PAU, or contained aortic rupture. Pain is the most commonly presenting symptom of acute aortic dissection and should prompt immediate attention including diagnostic imaging modalities (such as multislice computed tomography, transoesophageal ultrasound, or magnetic resonance imaging). Prognosis is clearly related to undelayed diagnosis and appropriate surgical repair in the case of proximal involvement of the aorta; affection of distal segments of the aorta may call for individualized therapeutic approaches favouring endovascular in the presence of malperfusion or imminent rupture, or medical management.