Aortic dissection: a rare but deadly heart emergency

When we think about heart health during February’s Heart Month, heart disease and heart attacks often take center stage. However, there is another life-threatening condition that affects the cardiovascular system, and it deserves attention: aortic dissection.

What is aortic dissection?

The aorta, the largest artery in the body, carries oxygen-rich blood from the heart to the rest of the body. The aortic wall is made of three layers that are packed together to increase strength. An aortic dissection occurs when the inner layer of the aortic wall tears, causing blood to flow between these layers. This can lead to severe complications, including rupture, decreased blood flow to vital organs and stroke.

Aortic dissections are classified into two main types based on their location.

• Type A aortic dissection: Dissections that affect the beginning part of the aorta or ascending aorta; these dissections are in close proximity to the heart and are more prone to rupture or complications. Therefore, immediate open surgery is indicated.
• Type B aortic dissection: Dissections that occur in the descending part of the thoracic aorta and that do not affect the ascending aortas; these are further from the heart and are typically managed with medication or minimally-invasive procedures unless complications arise.

“Proximal dissections, or type A dissections, can rapidly become life-threatening because they affect critical areas like the heart, brain and coronary arteries,” said Dr. Anna Xue, Baylor Medicine heart surgeon. “Early detection and emergency surgery are key.”

While distal dissections, or Type B dissections, are generally less urgent and often managed with medication, they can still lead to severe complications such as organ damage or aneurysm formation.

How does an aortic dissection differ from a heart attack?

Aortic dissections and heart attacks share some overlapping symptoms and therefore it is important that both diagnoses be considered during the initial evaluation. However, the two conditions share some important distinctions:

• A heart attack occurs when blood flow to the heart muscle is blocked, usually due to a clot in the coronary arteries.
• An aortic dissection involves a tear in the wall of the aorta, the main artery leading out of the heart. If the dissection causes blockage in the arteries of the heart, the patient can present also with heart attack from the dissected aorta.
• In both cases the diagnosis is usually determined emergently using a combination of physical exam, laboratory tests and imaging with computed tomography and/or echocardiogram.

Symptoms of an aortic dissection can include:

• Severe, sharp or tearing pain in the chest, back or abdomen
• Shortness of breath
• Weakness or numbness in the limbs
• Fainting or dizziness
• Difficulty speaking or stroke-like symptoms

“The chest pain from an aortic dissection is often described as tearing or ripping, and it may move from the chest to the back,” Xue said. “If you experience symptoms like these, seek medical care immediately.”

Understanding risks

While aortic dissections are less common than heart attacks, they remain a serious threat, affecting approximately three to four people per 100,000 annually. Risk factors include:

• High blood pressure
• Existing aortic aneurysms
• Connective tissue disorders (e.g., Marfan syndrome)
• Family history of aortic disease
• Advanced age
• Smoking

“If you have a family history of aortic conditions or connective tissue disorders, regular screening is essential to catch potential problems early,” Xue said.

Treatment, recovery for proximal dissections

Proximal dissections often require emergency surgery to replace the damaged section of the aorta with a synthetic graft.

Recovery involves several days in the intensive care unit for close monitoring, followed by a hospital stay for about two weeks. Patients gradually regain strength through cardiac rehabilitation, with full recovery taking weeks to months. Long-term management includes blood pressure control, lifestyle modifications, regular follow-ups and lifelong surveillance.

Treatment, recovery for distal dissections

Depending on the severity, distal dissections may be managed with blood pressure control or treated with minimally-invasive thoracic endovascular aortic repair (TEVAR). The best treatment depends on the size and location of the aneurysm and the patient’s health. Doctors use advanced imaging, like CT scans, to plan the safest and most effective approach, whether that be open surgery or a less invasive way called an endovascular approach.

With TEVAR, a surgeon uses small punctures or incisions and catheter-based technology to place a stent graft inside the affected artery. This stent provides structural support and redirects blood flow, reducing pressure on the dissection or aneurysm and significantly lowering the risk of rupture. Endovascular repair can be performed in almost any location of the aorta, including the abdominal aorta (EVAR), thoracic aorta (TEVAR) and the segments that affect the blood vessels to the head and neck (arch aortic repair) or the arteries to the liver, intestines and kidneys (thoracoabdominal aortic repair).

An endovascular repair can be performed in the abdominal aorta (EVAR), thoracic aorta (TEVAR) and the segments that affect the blood vessels to the head and neck (arch aortic repair) or the arteries to the liver, intestines and kidneys (thoracoabdominal aortic repair). In patients with dissections that develop into chronic aneurysms that affect the side branches of the aorta, standard EVAR or TEVAR procedure may not be feasible. In these cases, special stents with side holes (fenestrations) and or side arms (branches) may be used to perform a fenestrated-branched endovascular aortic repair (FB-EVAR).

Currently, open surgery is reserved for the younger and lower-risk patients who have underlying genetic predisposition to aneurysms and those who do not qualify for an endovascular approach due to anatomical limitations.

“Endovascular aortic aneurysm repair is a less invasive way to treat abdominal aortic aneurysms and dissections,” said Dr. Gustavo Oderich, vascular surgeon and director of the Baylor Medicine Aortic Center. “It has many benefits, including less blood loss, shorter surgery time and a faster recovery compared to open surgery. And here at Baylor, we have access to the entire pipeline of special fenestrated and branched stent-grafts, several of which are only available at a few centers in the U.S.”

These stents are made to fit the patient’s anatomy and make total endovascular repair possible for complex cases. Studies show an endovascular approach to be highly effective with high technical success rates and lower risks than traditional open surgery.

“Advances in imaging and endovascular technology have greatly improved outcomes for patients with aortic aneurysms and dissections, making recovery smoother and safer,” Oderich said.

Post-operative recovery involves careful monitoring, lifelong imaging to track the aorta and adopting a heart-healthy lifestyle.

By Tiffany Harston, senior communications specialist in the Michael E. DeBakey Department of Surgery