Morphologic characteristics for treatment guidance in uncomplicated acute type B aortic dissection.

A 79-year-old woman with an event-less cardiovascular medical history presented at the emergency department with acute-onset chest pain radiating to the back, accompanied by nausea, vomiting , and profuse sweating. The patient was hemodynamically stable, with a blood pressure of 130/70 mm Hg in both arms and heart rate of 60 beats per minute ; the ECG showed no signs of cardiac ischemia, and cardiac biomarkers were not elevated. A computed tomography scan of the chest and abdomen showed a Stanford type B dissection of the aorta (Movies I and II in the online-only Data Supplement), which extended to the suprarenal aorta, not involving the renal arteries. The celiac trunk and superior mesenteric artery originated from the false lumen, without signs of mesen-teric ischemia. The patient was treated medically with intravenous labetalol, targeted at a heart rate <60 beats per minute (with systolic blood pressure <120 mm Hg), and analgesia. A second computed tomography scan 3 days after admission showed a stable dissec-tion with progressive thrombosis of the false lumen. In the following days, the patient's heart rate and blood pressure remained within the target range with IV labetalol, pain was adequately treated with opioids, and the labetalol dose was lowered gradually. At day 6 after admission , the patient suddenly developed excruciating thoracic and abdominal pain, became hemodynamically unstable shortly thereafter, and died because of rupture of the dissection. Acute type B aortic dissection is the most common aortic catastrophe and is associated with high morbidity and mortality rates. Patients with acute aortic dissection (AoD) can present with a variety of signs and symptoms that mimic other more common disease modalities. Therefore, a high index of suspicion is warranted in patients at risk for AoD, such as those with hypertension, use of cocaine or other stimulants, a family history of thoracic aneurysm or AoD, presence of genetic collagen-vascular disorders (eg, Marfan or Ehlers-Danlos syndrome), and inflammatory vasculitides (eg, Takayasu or giant cell arteritis). 4 Most patients present with sudden severe chest, back, or abdominal pain, which may have a radiating or migratory pattern. These symptoms sometimes resolve, whereas dissection-related complications, such heart failure, pulse deficit, neurologic deficits, or other signs of vascular insufficiency, persist. Modalities to diagnose AoD include echocardiography, abdominal ultra-sound, and computed tomography scan. Of these modalities, computed tomography scan has the highest sensitivity and specificity. 4 However, these imaging modalities should not be considered as competitive …