Neue Risikoeinschätzung der Aortendissektion

Abstract

Acute aortic dissection is a multi-facetted disease often associated with fatal outcome. The common denominator of aortic dissection is disruption of the media layer of the aorta with possible complications like sidebranch compromise malperfusion, neurological impairment, pericardial tamponade and cardiogenic shock depending on location and expansion of the dissection. An undelayed diagnostic and therapeutic management are key to successful treatment.

Population-based studies suggest that the incidence of acute dissection ranges from 3 to 4.5 cases per 100 000 person-years. Hypertension, genetic disorders and trauma are the most prevalent risk conditions. Patients with acute aortic dissection often present a with a variety of symptoms with acute chest or back pain as the most commonly presenting symptom, which should rise the awareness for this differential diagnosis. Diagnostics include imaging modalities (such as multislice computed tomography, transoesophageal ultrasound interrogation, or magnetic resonance imaging). Prognosis is clearly related to undelayed and appropriate treatment of Type A and Type B aortic dissection. In case of Type A dissection, surgical repair is required in most instances; conversely, type B dissection is a call for individualized therapeutic approaches favoring endovascular graft-stenting in the presence of complications in addition to blood pressure control, and medical management for uncomplicated cases with an option for preemptive endovascular treatment in most suitable cases. All patients need life-long surveillance regardless of therapy.

Kernaussagen

• Die Aortendissektion ist ein akutes, lebensbedrohliches Krankheitsbild, das ohne schnelle und gezielte Diagnostik und Therapie eine äußerst ungünstige Prognose hat.

• Das Hauptsymptom ist der akute Thoraxschmerz. Die klinische Symptomatik kann von neurologischen Symptomen überlagert sein und zu Fehldiagnosen und Zeitverlust führen.

• Die Diagnostik der Wahl beinhaltet eine frühzeitige, suffiziente Bildgebung. Hierbei stehen CT, TEE und MRT im Vordergrund.

• Das Spektrum von akuten Komplikationen reicht von Myokardinfarkt, Perikardtamponade und Aortenruptur bis zur klinisch inapparenten Malperfusion von Organen oder Extremitäten.

• Eine Typ-A-Dissektion wird chirurgisch versorgt.

• Typ-B-Dissektionen sollten in Abhängigkeit von Risikokonstellationen konservativ, medikamentös oder zusätzlich interventionell mit TEVAR behandelt werden.

• Das Spektrum der Risikomerkmale einer Typ-B-Dissektion erweitert sich von Zeichen der Organ- und Extremitätenmalperfusion und drohender Ruptur mit Hypotonie und Schockzeichen um persistierende Schmerzsyndrome, refraktäre Hypertonie, frühzeitige klinisch inapparente Expansion des falschen Lumens, großes Entry, Inflammation der dissezierten Aortenwand und partieller Thrombosierung des falschen Lumens.

• Literatur

• 1 Rosman HS, Patel S, Borzak S et al. Quality of history taking in patients with aortic dissection. Chest 1998; 114: 793-795
• 2 Hansen MS, Nogareda GJ, Hutchison SJ. Frequency of and inappropriate treatment of misdiagnosis of acute aortic dissection. Am J Cardiol 2007; 99: 852-856
• 3 Howard DP, Banerjee A, Fairhead JF et al. Population-based study of incidence and outcome of acute aortic dissection and premorbid risk factor control: 10-year results from the Oxford Vascular Study. Circulation 2013; 127: 2031-2037
• 4 Acute aortic dissection: population-based incidence compared with degenerative aortic aneurysm rupture. Mayo Clinic proceedings 2004; 79: 176-180
• 5 Olsson C, Thelin S, Stahle E et al. Thoracic aortic aneurysm and dissection: increasing prevalence and improved outcomes reported in a nationwide population-based study of more than 14,000 cases from 1987 to 2002. Circulation 2006; 114: 2611-2618
• 6 Hagan PG, Nienaber CA, Isselbacher EM et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA 2000; 283: 897-903
• 7 Suzuki T, Mehta RH, Ince H et al. Clinical profiles and outcomes of acute type B aortic dissection in the current era: lessons from the International Registry of Aortic Dissection (IRAD). Circulation 2003; 108: II312-II317
• 8 Klompas M. Does this patient have an acute thoracic aortic dissection?. JAMA 2002; 287: 2262-2272
• 9 Hirst AE Jr, Johns VJ Jr, Kime SW Jr. Dissecting aneurysm of the aorta: a review of 505 cases. Medicine 1958; 37: 217-279
• 10 Erbel R, Alfonso F, Boileau C et al. Diagnosis and management of aortic dissection. Eur Heart J 2001; 22: 1642-1681
• 11 O’Gara PT, DeSanctis RW. Acute aortic dissection and its variants. Toward a common diagnostic and therapeutic approach. Circulation 1995; 92: 1376-1378
• 12 Golledge J, Eagle KA. Acute aortic dissection. Lancet 2008; 372: 55-66
• 13 Akin I, Kische S, Rehders TC et al. Acute aortic syndromes. Medicine 2010; 38: 450-455
• 14 Reed D, Reed C, Stemmermann G et al. Are aortic aneurysms caused by atherosclerosis?. Circulation 1992; 85: 205-211
• 15 Nienaber CA, Powell JT. Management of acute aortic syndromes. EHJ 2012; 33: 26-35b
• 16 von Kodolitsch Y, Schwartz AG, Nienaber CA. Clinical prediction of acute aortic dissection. Archives of internal medicine 2000; 160: 2977-2982
• 17 Slater EE, DeSanctis RW. The clinical recognition of dissecting aortic aneurysm. Am J Med 1976; 60: 625-633
• 18 Bossone E, Rampoldi V, Nienaber CA et al. Usefulness of pulse deficit to predict in-hospital complications and mortality in patients with acute type A aortic dissection. Am J Card 2002; 89: 851-855
• 19 Hazui H, Fukumoto H, Negoro N et al. Simple and useful tests for discriminating between acute aortic dissection of the ascending aorta and acute myocardial infarction in the emergency setting. Circulation journal: official journal of the Japanese Circulation Society 2005; 69: 677-682
• 20 Eggebrecht H, Naber CK, Bruch C et al. Value of plasma fibrin D-dimers for detection of acute aortic dissection. JACC 2004; 44: 804-809
• 21 Shiga T, Wajima Z, Apfel CC et al. Diagnostic accuracy of transesophageal echocardiography, helical computed tomography, and magnetic resonance imaging for suspected thoracic aortic dissection: systematic review and meta-analysis. Archives of internal medicine 2006; 166: 1350-1356
• 22 Johnson TR, Nikolaou K, Wintersperger BJ et al. ECG-gated 64-MDCT angiography in the differential diagnosis of acute chest pain. AJR 2007; 188: 76-82
• 23 Hiratzka LF, Bakris GL, Beckman JA et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation 2010; 121: e266-e369
• 24 Nienaber CA, Rousseau H, Eggebrecht H et al. Randomized comparison of strategies for type B aortic dissection: the INvestigation of STEnt Grafts in Aortic Dissection (INSTEAD) trial. Circulation 2009; 120: 2519-2528
• 25 Nienaber CA, Kische S, Rousseau H et al. Endovascular repair of type B aortic dissection: long-term results of the randomized investigation of stent grafts in aortic dissection trial. Circulation Cardiovascular interventions 2013; 6: 407-416
• 26 Fattori R, Cao P, De Rango P et al. Interdisciplinary expert consensus document on management of type B aortic dissection. JACC 2013; 61: 1661-1678
• 27 Fattori R, Tsai TT, Myrmel T et al. Complicated acute type B dissection: is surgery still the best option? A report from the International Registry of Acute Aortic Dissection. . JACC 2008; 1: 395-402
• 28 Tsai TT, Fattori R, Trimarchi S et al. Long-term survival in patients presenting with type B acute aortic dissection: insights from the International Registry of Acute Aortic Dissection. Circulation 2006; 114: 2226-2231
• 29 Trimarchi S, Eagle KA, Nienaber CA et al. Importance of refractory pain and hypertension in acute type B aortic dissection: insights from the International Registry of Acute Aortic Dissection (IRAD). Circulation 2010; 122: 1283-1289
• 30 Tsai TT, Evangelista A, Nienaber CA et al. Partial thrombosis of the false lumen in patients with acute type B aortic dissection. NEJM 2007; 357: 349-359
• 31 Evangelista A, Salas A, Ribera A et al. Long-term outcome of aortic dissection with patent false lumen: predictive role of entry tear size and location. Circulation 2012; 125: 3133-3141
• 32 Kato K, Nishio A, Kato N et al. Uptake of 18F-FDG in acute aortic dissection: a determinant of unfavorable outcome. Journal of nuclear medicine: official publication, Society of Nuclear Medicine 2010; 51: 674-681
• 33 Acosta S, Blomstrand D, Gottsater A. Epidemiology and long-term prognostic factors in acute type B aortic dissection. Annals of vascular surgery 2007; 21: 415-422