Aortic dissection is a life-threatening condition in which a tear in the aortic wall creates a false lumen. This disrupts normal blood flow and may lead to rupture or organ ischemia.
Diagnosis relies on advanced imaging methods such as CT angiography, MRI, or transesophageal echocardiography. Prompt identification is critical for survival.
Treatment strategies depend on the location and severity of the dissection. Medical therapy with blood pressure control is used in stable cases, while surgery or endovascular stent grafting is required in complicated cases.
Early recognition and appropriate management significantly improve survival rates. Multidisciplinary care ensures optimal outcomes for patients with this critical vascular emergency.
| Definition | – A serious and life-threatening condition where a tear in the inner layer (intima) of the aorta allows blood to flow between the wall layers, creating a dissection or “split.” |
| Symptoms | – Sudden and severe chest or back pain (described as stabbing) Abdominal painShortness of breath Fainting or loss of consciousness Sudden drop or asymmetry in blood pressure (between arms or legs) |
| Causes | – Hypertension (high blood pressure) Connective tissue diseases (e.g., Marfan syndrome, Ehlers-Danlos syndrome)Aortic coarctation Trauma or post-surgical complications Advanced age |
| Risk Factors | – High blood pressure SmokingMale gender Family history of aortic disease Connective tissue disorders Atherosclerosis (arterial hardening) |
| Types | – Type A: Tear in the ascending part of the aorta (requires emergency surgery). Type B: Tear in the descending part of the aorta (may require medical or surgical treatment). |
| Diagnostic Methods | – CT angiography Transthoracic or transesophageal echocardiography (TTE/TEE)Magnetic resonance imaging (MRI) Chest X-ray (shows widened mediastinum) |
| Treatment Options | – Type A Dissection: Emergency surgery (repair or replacement of the torn aorta with a graft). Type B Dissection: Medication to control blood pressure (beta-blockers) and stent graft placement if necessary. |
| Complications | – Complete rupture of the aorta Organ failures (kidney, brain, intestines)Cardiac tamponade Stroke Death |
| Prevention | – Keeping blood pressure under control Adopting a healthy lifestyle (regular exercise, quitting smoking and alcohol)Regular screening for aortic aneurysms (especially in high-risk individuals) |
Prof. Dr. Özgür KILIÇKESMEZ
Interventional Radiology / Interventional Neuroradiology
Prof. Dr. Kılıçkesmez holds the Turkish Radiology Competency Certificate, the Turkish Interventional Radiology Competency Certificate, Stroke Treatment Certification, and the European Board of Interventional Radiology (EBIR). In his academic career, he won the Siemens Radiology First Prize in 2008.
What Exactly Is Aortic Dissection?
Aortic dissection is an acute condition that occurs when a tear develops in the inner layer of the aortic wall, allowing blood to enter between the layers of the vessel wall. As a result, two separate “channels” (lumens) form inside the vessel: a “true lumen” and a “false lumen.” Sometimes, blood may flow through both lumens, but usually blood entering the false lumen further weakens the vessel wall. This can be compared to a leak in a pipe that grows larger over time. If the tear widens or if there are additional weak spots in the vessel wall, the risk of a complete rupture increases—this is life-threatening.
Aortic dissection usually develops due to two main problems:
- Weakening of the vessel wall (from genetic factors, connective tissue diseases, or degeneration due to high blood pressure)
- Intense pressure on the wall (increased mechanical stress from conditions like hypertension)
When these two factors combine, high blood pressure can tear the inner layer and allow blood to advance between the wall layers.
What Causes Aortic Dissection?
Main risk factors for aortic dissection include:
High Blood Pressure (Hypertension): Consistently high blood pressure puts constant force on the aortic wall, which can weaken its structure over time—similar to how fast-moving water wears down a pipe.
Connective Tissue Disorders: In genetic diseases such as Marfan or Ehlers-Danlos syndrome, the proteins that provide elasticity to the vessel wall (like collagen and elastin) may be insufficiently robust, making the vessel more prone to tearing.
Aortic Aneurysm: Aneurysm, which is a ballooning of the aorta, causes the vessel wall to thin and stretch. These thinned areas are more likely to dissect.
Family Predisposition: Some genetic mutations or family histories can weaken the vessel wall.
Other Factors: Severe trauma, or the use of drugs such as cocaine that cause sudden spikes in blood pressure, can also trigger dissection.
What Are the Symptoms and How Does Aortic Dissection Feel?
Aortic dissection typically presents as a sudden, severe, tearing-type chest or back pain. The pain is often described as “starting in the middle of the chest and radiating to the back,” but not everyone experiences it the same way. Other possible symptoms include:
Fainting or Loss of Consciousness: If the dissection affects blood flow to the brain, dizziness or fainting can occur.
Shortness of Breath: If the dissection is near the heart, the heart valves may be affected, or fluid may accumulate around the heart (pericardial effusion).
Numbness or Weakness in the Arms or Legs: Especially if the “false lumen” blocks blood flow to certain branches, insufficient blood supply may occur in the arms, legs, or organs (brain, kidneys, intestines).
Blood Pressure Differences: There may be a difference in blood pressure between the arms or between an arm and a leg.
Aortic dissection can be confused with a heart attack or lung-related pain. Therefore, any sudden chest or back pain described as a “tearing sensation,” or numbness in the limbs, should be taken seriously.
How Is Aortic Dissection Diagnosed?
Doctors may suspect aortic dissection in anyone presenting to the hospital with sudden chest or back pain. Diagnostic methods include:
Computed Tomography Angiography (CT Angio): Often the first choice, providing detailed cross-sectional images of the vessel. It can show the true and false lumens and entry/exit points.
Transthoracic or Transesophageal Echocardiography (TTE/TEE): Particularly useful for dissections near the heart. TEE, using a probe in the esophagus, allows close-up imaging of the aorta.
Magnetic Resonance Angiography (MR Angio): No radiation exposure, but may take longer—more suitable for stable patients.
Digital Subtraction Angiography (DSA): Used for planning and performing interventional radiology procedures. Provides real-time vessel images for both diagnosis and treatment.
Several different “angiography” techniques may be used, and DSA in particular acts as a “road map” for interventional radiologists during catheter-based procedures.
What Does Interventional Radiology Do in Treatment?
Interventional radiology uses imaging guidance (CT, ultrasound, angiography) to perform various endovascular treatments—often avoiding open surgery. In aortic dissection, the key role is placement of a stent-graft (endovascular repair). The steps are:
Vascular Access: Usually via a small incision in the groin (femoral artery), but sometimes the arm (brachial or radial artery).
Advancing Catheter and Guidewire: Fine, flexible catheters are advanced into the aorta, guided by wires—think of a rope and a hose working together.
Injection of Contrast Agent: Contrast is injected and X-ray images are taken to precisely locate the dissection.
Stent-Graft Placement: A specially designed stent-graft is positioned to cover the entry and exit of the false lumen, creating an internal “new pipe” and sealing off the false channel.
Verification: After placement, repeat angiography checks for correct stent positioning and absence of leaks.
This “closed” approach often requires less recovery time than open surgery. However, the choice of treatment is made by a multidisciplinary team—including vascular surgeons, cardiologists, anesthesiologists, and interventional radiologists.
What Are Other Treatment Options for Aortic Dissection?
There are three main approaches:
Medical Management: Medications, mainly beta-blockers, to control blood pressure and reduce stress on the vessel wall—aiming to slow or stop the progression of the dissection.
Surgical Intervention (Open Surgery): Especially required for ascending aorta (Type A) dissections. The damaged segment is replaced with a synthetic graft, and the aortic valve may be repaired or replaced if needed.
Endovascular Repair (Interventional): Most often used for descending aorta (Type B) dissections, involving stent-graft placement via angiography. In some cases, a “hybrid” approach may combine surgery and endovascular repair.
The choice of approach depends on the location and extent of the dissection, the patient’s general health, and other organ involvement.
How Is Endovascular Repair (TEVAR) Performed?
Thoracic Endovascular Aortic Repair (TEVAR) is frequently used for aortic dissection or aneurysm in the chest area. Steps include:
Planning and Preparation: CT or MR angiography determines the size and position of the dissection, and helps select the appropriate stent-graft.
Anesthesia and Vascular Access: Usually performed under general anesthesia via a small groin incision.
Stent-Graft Delivery: The stent-graft is transported to the target area inside a special sheath, like a folded umbrella.
Positioning and Deployment: Guided by X-ray images, the stent-graft is positioned to seal the entry point of the dissection and then deployed.
Verification: After deployment, contrast is injected again to check stent position and blood flow.
Monitoring and Recovery: The patient is closely monitored in the ICU or high-dependency unit, with attention to blood pressure and early detection of complications.
What Is Recovery Like After Endovascular Treatment?
Endovascular repair typically means a shorter hospital stay and quicker recovery than open surgery, but this varies by patient. Recovery may take from a few days to several weeks. Important considerations:
Blood Pressure Control: Continued medication is crucial to prevent new tears.
Anticoagulant Therapy: If necessary, blood thinners may be used to reduce clot risk.
Care of Access Site: Monitor the groin or other access sites for redness, swelling, or leakage.
Regular Follow-up: Imaging (CT or MR angiography) is often required in the first weeks and months to monitor the stent-graft and healing.
Lifestyle Adjustments: Quitting smoking, regular gentle exercise, and reducing salt intake help control blood pressure.
Patients with connective tissue disorders require lifelong follow-up due to the risk of recurrence.
What Should Be Done in Aortic Dissection Emergencies?
Sudden, severe, “tearing” chest or back pain requires immediate medical attention. Other urgent symptoms include fainting, neurological changes (numbness, speech difficulty), and shortness of breath.
- Call emergency services (e.g., 112) and get to the nearest hospital as quickly as possible.
- If possible, record your blood pressure and share it with the medical team, but do not self-medicate without medical advice.
- Rapid diagnosis and planning (CT angiography, echocardiography) are critical in the hospital setting.
Quick transport to the right facility improves survival.
What Is the Role of Angiography in Aortic Dissection?
Angiography is key for both diagnosis and treatment:
Diagnostic: Shows the location and extent of the tear and branch vessel involvement.
Guidance for Procedures: Acts as a “map” during stent-graft placement, angioplasty, or additional stenting.
Real-Time Monitoring: Contrast injection allows for immediate detection of leaks or blockages.
Follow-Up and Additional Procedures: Repeat angiography may be done if stent position changes or new narrowing appears.
Angiography is performed by inserting a catheter into a large vessel, injecting contrast, and capturing detailed images—often enhanced with digital subtraction techniques (DSA).
Life After Aortic Dissection: What Should Be Watched For?
Lifestyle changes are essential:
Blood Pressure and Regular Check-Ups: Monitor blood pressure regularly and take medications as prescribed. Routine imaging follow-ups are necessary.
No Smoking or Alcohol: Smoking damages vessel walls and raises blood pressure; it should be stopped. Alcohol can also affect blood pressure and should be consumed only with caution.
Physical Activity: Light-to-moderate exercise helps heart health and blood pressure control, but avoid strenuous, heavy-lifting activities.
Regular Medical Follow-Up: Stay in contact with your healthcare team, especially if you have underlying connective tissue disorders.
Aortic dissection can recur, so never neglect regular check-ups.
FAQ
Is aortic dissection the same as an aortic aneurysm?
No. An aneurysm is a ballooning or dilation of the vessel wall. A dissection is a tear in the wall, allowing blood to enter between layers. An aneurysm can increase the risk of dissection, but they are different conditions.
Is endovascular repair a permanent solution?
It aims to block blood flow into the false lumen, but long-term follow-up is essential. Additional interventions may be required over time.
Will I feel pain during the procedure?
Most procedures are performed under general anesthesia or sedation, so pain is usually minimal. Mild discomfort or pressure may be felt at the access site.
Can young people develop this problem?
Yes—especially those with connective tissue diseases or genetic predisposition. Drug use or sudden, extreme hypertension can also cause dissection in young people.
When is open surgery preferred, and when endovascular procedures?
Location matters: ascending aorta (Type A) usually requires surgery; descending aorta (Type B) may be managed endovascularly. The decision depends on overall health and specifics of the case.
Is there a risk of recurrence?
Unfortunately, some patients may experience recurrence. Regular follow-up and blood pressure control are crucial.
How long does an interventional radiology procedure take?
It depends on the dissection’s location and extent, but generally takes 1–3 hours. More complex cases may take longer.
How long will I stay in the hospital after the procedure?
Depending on your situation, you may stay in the ICU or general ward for a few days up to a week, based on your recovery.
Interventional Radiology and Neuroradiology Speaclist Prof. Dr. Özgür Kılıçkesmez graduated from Cerrahpaşa Medical Faculty in 1997. He completed his specialization at Istanbul Education and Research Hospital. He received training in interventional radiology and oncology in London. He founded the interventional radiology department at Istanbul Çam and Sakura City Hospital and became a professor in 2020. He holds many international awards and certificates, has over 150 scientific publications, and has been cited more than 1500 times. He is currently working at Medicana Ataköy Hospital.
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