Aortic Dissection and Aneurysm

Aortic Dissection

65 y/o M with h/o HTN present with acute back pain. Pain is inter-scapular and tearing in nature. Reports syncopal episode s/p pain onset. Asymmetric blood pressure and upper extremity pulses on exam.

• CT with contrast shows dissection

• Contraindication to IV contrast: Obtain transthoracic (TTE) and/or transesophageal echo

• Treatment

  • Start IV esmolol to reduce LV ejection velocity

  • Start IV nitroprusside to lower systolic blood pressure to 90-110 mmHg

Note: Syncope occurs in 9% of patients with aortic dissection

Abdominal Aortic Aneurysm (AAA) Screening

• Etiology and Epidemiology

  • Due to atherosclerosis

  • Affects 2-5% of patients > 65

  • Approximately 5:1 male:female predominance

• USPSTF recommends one-time screening for AAA with ultrasound in men ages 65-75 who have ever smoked (i.e. >100 cigarettes in a lifetime)

• Management based on diameter:

  • AAA < 5.5 cm in men: Repair for growth > 0.5 cm in 6 months or > 1 cm per year

    • Aneurysm 3.0 to 4.0 cm: Ultrasound yearly

    • Aneurysm 4.0 to 5.5 cm: Ultrasound every 6 months for one year and then yearly if no growth

  • AAA > 5.5 cm in men or > 5.0 cm in women:

    • Life expectancy > 2 years and a surgical candidate: Refer for surgical endovascular repair

    • Life expectancy < 2 years: Do not repair

Abdominal Aortic Aneurysm Rupture

65 y/o M with a h/o HTN, AAA, and Marfan’s syndrome presents with acute onset abdominal pain radiating to the flank and groin. Reports associated vomiting and syncope. Hypotension on exam with a pulsatile abdominal mass.

• STAT non-contrast abdominal CT shows AAA rupture

• Obtain STAT vascular surgery consult

• Patient’s family counseled that condition is associated with 80% mortality rate