The specialist aortic team at RB&HH Specialist Care treat patients with diseases of the thoracic aorta. Professor Christoph Nienaber, an integral member of the team, takes us through a case study of aortic dissection.

Aortic dissection occurs when a tear in the inner wall of the aorta causes blood to flow between the layers of the wall of the aorta, forcing the layers apart. Even with optimal treatment, aortic dissection can quickly lead to death, as a result of decreased blood supply to other organs, heart failure, and sometimes rupture of the aorta. It should be treated as a medical emergency.

Patients are at higher risk of suffering aortic dissection if they have a history of high blood pressure, a known thoracic aortic aneurysm, or some connective tissue diseases that affect blood vessel wall integrity such as Marfan syndrome and Ehlers–Danlos syndrome.

The majority of patients (96 per cent) that present with aortic dissection have experienced a severe pain with a sudden onset. The pain may be described as tearing, stabbing, or sharp in character. Through the use of medical imaging technologies such as CT and MRI scans or echocardiography, our consultants are able to diagnose aortic dissection to decide the best approach for treatment.

Types of aortic dissection

Proximal aortic dissection (type A) is the more life threatening variant and needs urgent diagnosis and undelayed surgical treatment. It affects middle aged and very old patients sometimes at extreme surgical risk. For some of these patients catheter based endovascular repair (without thoracotomy) can be an option that Royal Brompton's aortic team may consider and offer to selected patients.

Descending aortic dissection (type B) has become the centre of spotlight for endovascular treatment, both in the acute setting (if necessary because of ongoing pain or malperfusion) and in the elective setting, weeks or months after it happened. The idea is to remodel the aorta thereby avoiding future problems.

Case Study

A previously healthy 84-year-old gentleman presented to the emergency room with undulating chest and back pain. Until recently he was actively engaging in recreational exercise and moderate weight lifting.

Once a normal electrocardiogram (ECG) was recorded, he was given a contrast-enhanced computed tomography (CT) imaging, revealing type B aortic dissection with a narrow true lumen and compromised perfusion of the left common iliac artery. 

Based on the individual biological condition without major life-limiting comorbidities, the patient was offered undelayed endovascular stent graft repair in the attempt to both reconstruct the dissected aorta and alleviate peripheral ischemia.

Thoracic endovascular aneurysm repair (TEVAR) was successfully performed and flow was successfully redirected to the true lumen after sealing proximal thoracic entries using an off-the-shelf commercial stent graft system extended by an open stent configuration. After completion of TEVAR, the patient recovered swiftly and left hospital within four days.

Royal Brompton's aortic team with Professor Christoph Nienaber, a pioneer and highly skilled leader in this field, provides catheter-based aortic repair for dissection, aneurysms, and malformations. Beside non–invasive work up and endovascular treatment, the aortic team offers lifelong surveillance to their patients.

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