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The Continuing Evolution in the Management of Thoracic Aortic Dissection

Riyad Karmy-Jones, MD, FCCP; Gabriel Aldea, MD, FCCP; Edward M. Boyle Jr., MD
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Affiliations: Seattle, WA 
 ,  Drs. Karmy-Jones, Aldea, and Boyle are from the Division of Cardiothoracic Surgery, University of Washington.

Correspondence to: Riyad Karmy-Jones, MD, FCCP, Department of Surgery, Harborview Medical Center, Box 359796, 325 Ninth Ave, Seattle, WA 98104; e-mail:riyad.karmy-jones@sos.washington.edu



Chest. 2000;117(5):1221-1223. doi:10.1378/chest.117.5.1221
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Dissection of the thoracic aorta presents some of the greatest challenges in cardiovascular disease. The diagnosis often requires clinical suspicion. Patients present with a spectrum of symptoms, which can include acute myocardial ischemia or failure, neurologic events, visceral ischemia, and/or peripheral vascular insufficiency. Chest radiographs may suggest the diagnosis. Echocardiography (transthoracic and transesophageal), CT scan, MRI, and angiography are all applicable and have sensitivity of 80 to 100%. Angiography is particularly useful if there is clinical evidence of“ malperfusion” of a critical branch vessel.1 Once the diagnosis is made, or if there is a suspicion of a diagnosis in an otherwise stable patient, the initial therapy includes antihypertensive therapy with β-blockers, maintaining systolic blood pressures of 110 to 120 mm Hg (or mean of 70 to 80 mm Hg). The subsequent management of aortic dissection is determined by the anatomic extent and the chronicity of presentation. The DeBakey classification includes the following: type I, the dissection involves the ascending aorta, arch, and the various lengths of the descending and abdominal aorta; type II, limited to the ascending aorta and proximal arch; type III, involving the aorta distal to the left subclavian artery, with IIIa being limited to the thoracic aorta, and IIIb involving various degrees of the thoracic abdominal aorta.2 In the Stanford classification, type A dissections are those that involve the ascending aorta regardless of the site and distal extent to the process, and type B are those that involve the aorta distal to the left subclavian artery.3 Dissections are further categorized as being acute or chronic, depending on whether or not the duration of symptoms prior to diagnosis is < 2 weeks.

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