Aortic Dissection Treatment in Delhi, India

Generally, there are two types of Aortic Dissection, namely:

1. Stanford Type A Aortic Dissection

   This occurs in the first part of the aorta, closer to the heart, and can be immediately life-threatening. This type is more commonly noticed than Type B and stretches through the whole length of the aorta.
   
   

2. Stanford Type B Aortic Dissection

   This begins farther down the aorta (descending aorta beyond the arch) and farther from the heart. This stretches from the descending aorta into the abdominal aorta without involving the first part of the aorta in the anterior of the chest.

Common signs and symptoms are as follows:

1. Sudden severe and sharp pain in the chest or upper back area is also linked to a tearing or stabbing feeling.
2. Dyspnoea.
3. Dizziness.
4. Low blood pressure levels
5. Diastolic heart murmur and faint heart sounds.
6. Rapid but weak pulse.
7. Sweating profusely.
8. Confusion.
9. Vision loss.
10. Stroke symptoms include hemiplegia and trouble while talking.
11. Difficulty in walking

Aortic dissection occurs because there is an underlying, slow breakdown of the cells that constitutes the walls of the aorta. These events go on slowly for several years, after which the aortic wall ultimately gives rise to a tear, leading to the aortic dissection.

Most cases of aortic dissections are caused by an underlying susceptibility that can be genetic or inherited. In other cases, the stress to the aortic wall resulting from regular high blood pressure levels can further weaken the aorta wall in vulnerable people, resulting in a tear and dissection.

Tears in the aorta generally occur in areas where the stress on the wall of the aorta is highest.

Aortic dissection must be diagnosed immediately as it is life-threatening, and surgery is required in severe cases. Doctors need to find out if patients have aortic dissection or the presence of other health ailments, like heart attack and stroke, which exhibit homogenous symptoms. Certain tests that may be performed comprise:

1. Chest X-Ray

   This test is not very specific and accurate but is quick and may help the diagnosis further.
   
   

2. Computed Tomography (CT) Scan

   This test gives the best view of the aorta during an emergency and can be done to check for the presence of an aneurysm or dissection. For aortic imaging, intravenous (IV) contrast dye may be required.
   
   

3. Transthoracic Echocardiogram

   This test involves using ultrasound to generate images of heart valves and chambers and the aortic root.
   
   

4. Transesophageal Echocardiogram (TEE)

   This test depicts more detailed pictures of heart valves and chambers as compared to a transthoracic echocardiogram and clearer views of the thoracic aorta.
   
   

5. Magnetic Resonance Imaging (MRI)

   This test uses magnetic and radio waves to generate thorough images of organs and structures inside the body, including the aorta. It gives moving pictures of the heart valves and chambers and blood flow through the aorta. This takes more time to perform than a typical CT scan.

Treatment is based upon the location of the tear and dissection. Immediate surgery is required for Type A aortic dissection. In contrast, Type B aortic dissection requires emergency surgery only if the dissection prevents blood flow to the vital organs, including kidneys, intestines, legs, or even the spinal cord. Meanwhile, less severe cases are often treated with medication initially; surgery is usually delayed until a complication arises.

Surgery and Endovascular Treatment:

Surgical options are as follows:

1. Graft Replacement

   Here, a portion of the damaged section of the aorta is detached, and in that place, a synthetic fabric tube (graft) is sewn directly.
   
   

2. Endovascular Stent-Graft Repair

   In this approach, a stent graft is used to repair the aorta from the inside. A small incision is formed in the groin, and a catheter, with the fabric-lined stent attached, is placed into the aorta under x-ray guidance. At the repair site, the stent-graft is released, providing support to the weakened region in the aorta.
   
   

3. Hybrid Approach

   A combination of conventional open surgery and endovascular stent-graft technique is used to repair the aorta. One of the most commonly performed hybrid procedures is the "elephant trunk" or "frozen elephant trunk" procedure, in which the segment of the aorta close to the heart and the aortic arch is replaced and repaired. An extra graft, or stent graft, is left dangling into the descending aorta.

Factors that increase the risk of developing aortic dissection are as follows:

1. Ongoing high blood pressure (hypertension). This is the most vital risk factor which causes direct damage to the layers of aortic tissue, thereby causing loss of elastic fibres along with a breakdown of the structures of the wall and increased stiffness.
2. Atherosclerosis
3. Aortic aneurysm. This refers to an irregular expansion or bulge in the aortic wall.
4. Aortic valve disease.
5. Congenital heart conditions such as a bicuspid aortic valve or Turner syndrome.
6. Connective tissue disorders like Marfan syndrome and Ehlers-Danlos syndrome are genetically linked and run among family members.
7. Other hereditary thoracic aortic conditions primarily affecting the aorta are also genetically linked.
8. Family history of aortic dissection.
9. Vasculitis, specifically aortitis. 
10. Traumatic injury to the chest.
11. Age between 50 and 65 years because the aortic wall diminishes its elasticity with progressing age.
12. Being pregnant and having high blood pressure levels
13. Indulging in activities that extend periods of high blood pressure levels, such as consumption of cocaine or amphetamine.
14. Vigorous powerlifting may increase the speed of development of aneurysms or dissection in susceptible people.

Aortic dissection can lead to:

1. Stroke
2. Aortic valve damage
3. Damage to internal organs.
4. Cardiac tamponade
5. Death.

1. Doctor consultation: Talk to the doctor to discuss any genetic conditions. If that increases the chances of aortic dissection, the doctor may recommend taking various medications to help avoid it.
2. Control of blood pressure. If patients have high blood pressure levels, it is advised to keep up with the medicines, diet, and exercise daily to control it.
3. Avoid smoking 
4. Incorporate heart-healthy habits by having whole grains, fruits, and vegetables daily. Along with these things, exercise regularly and be very punctual about it.

Aortic dissection can be a life-threatening condition. People with acute aortic dissection (sudden onset, Type A) have a relatively lower survival rate. On average, 15% to 30% of people die even after surgery.

People who survive after surgery for the acute phase usually present with a chronic dissection left in the untreated portions of their aorta as it requires treatment at a later stage.

With the latest developments in treatment, the prognosis in the chronic phase is getting better daily. Still, life expectancy for people with aortic dissection is shortened compared to the general population.

Reviewed by Dr. Achintya Sharma, Consultant & In-charge, Vascular Surgery on 28-June-2022

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