Ascending aortic aneurysms may undergo internal tearing or dissection resulting in an extremely high mortality of up to 1% per minute and 60% in 60 minutes. Thus, time-consuming investigations that are not sufficiently sensitive or specific, such as CTscans, are usually not recom¬mended. Emergency surgery carries the only hope of sur¬vival for patients with dissecting aneurysms, and immediate accurate diagnosis is mandatory to guide therapy.
A. Signs and Symptoms
Sudden onset of severe chest and interscapular pain is common in aortic dissection. The pain is sudden like a gunshot, while heart attack pain builds up gradually over several minutes. The pain is described as a tearing or ripping sensation that becomes rapidly unbearable resulting in a shock-like state. In this state the patient’s skin is cold and clammy with impaired sensorium. Although the blood pressure may remain in the normal range or sometimes be increased, hypotension may occur from external rupture; this is an ominous sign. Syncope usually indicates a rupture into the pericardial sac with cardiac tamponade. A new loud aortic diastolic murmur may be heard and the pulses may be lost in one or more limb.
The majority of patients with aortic dissection are hypertensive and older than 60. Normotensive younger patients usually have associated underlying disease of the aortic root that includes Marfan syndrome. This is a leading cause of aortic dissection in patients under 40. Other causes include giant cell arteritis, lupus erythema-tosus, Ehlers-Danlos syndrome, Noonan and Turner’s syndrome, and relapsing polychondritis. Approximately 15% of patients with coarctation of the aorta die from aortic dissection.

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