Dr. Jason Glotzbach says this can become a critically dangerous problem with few warning symptoms, but people suffering from it usually experience severe pain. Learn about the two types of aortic dissection, what can cause them, and how they're treated.">

Aug 18, 2017 — Sometimes the aorta—the largest blood vessel in our bodies—can tear, allowing blood to flow between layers of the aortic wall. This dissection can block blood from flowing to other parts of the body, including the brain and other vital organs. Cardiac surgeon Dr. Jason Glotzbach says this can become a critically dangerous problem with few warning symptoms, but people suffering from it usually experience severe pain. Learn about the two types of aortic dissection, what can cause them, and how they're treated.

Interview

Interviewer: You have a loved one and you've been told they have an aortic dissection. What does that mean for them in the short term, and more importantly, the long term? That's next on The Scope.

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Interviewer: Dr. Jason Glotzbach is a cardiothoracic surgeon at University of Utah Health Care and if somebody's been diagnosed with an aortic dissection, let's kind of break that down a little bit and help them understand what that means. Generally, it's probably not going to be that person that had it that will be finding out this information because it's a serious thing.

Dr. Glotzbach: Absolutely. So the aorta, as we've talked about, is the largest blood vessel in the body and the aorta has several layers to the aortic wall. It's kind of like plywood where the layers should be stuck together without any space in between them and sometimes due to high blood pressure or other things, you can get a small tear in the inside of the aorta, which then allows blood to travel in between the layers of the aortic wall. We call it dissection because it dissects into the aorta and then once that blood gets in between the layers of the wall and separates them, that can cause major problems with the aorta.

Interviewer: So when it's in between those layers is it going to break out eventually and you'll be internally bleeding or what happens at that point?

Dr. Glotzbach: It can proceed to that, although more that's rare. More commonly, the blood dissection inside the wall of the aorta will travel kind of along the length of the aorta and it can block off the branches coming off the aorta. So it can prevent blood flow from going to all the branches of the aorta which can affect any area of the body because of those arteriole branches.

Interviewer: Including the brain?

Dr. Glotzbach: Absolutely, so it can involve the carotid arteries. Obviously if the carotid artery blood flow is decreased or impaired and then it can cause a stroke. Similarly, the blood vessels going to the liver or the spleen or the kidneys or the intestines, if those are blocked off then you can have major problems in the abdomen. So it really is a critically dangerous problem once it develops.

Interviewer: And I understand that there are two different types of aortic dissections that somebody might be diagnosed with. For the understanding of, you know, a loved one that might have another loved one that's dealing with this, could you explain briefly what those two are?

Dr. Glotzbach: Absolutely, and we break it down anatomically by kind of location within the aorta and so the two types are type A and type B. Type A aortic dissection involves the first part of the aorta coming right off the heart, so also known as the ascending aorta. And a type A dissection is a surgical emergency. Those patients need to go as quickly as possible to the operating room with a cardiovascular surgeon to repair that.

Type B aortic dissection involves the rest of the aorta, so from the aortic arch on down and including the abdomen. And so type B dissections are a little bit more complicated or nuanced in that they may require surgery or a procedure. They might not, but they definitely would need to be in the hospital. So those two distinctions are critical for the initial treatment phase, although all aortic dissections really should be thought of as a chronic disease and so once this happens to the aorta, patients will need lifelong surveillance with imaging studies and follow up with an aortic specialist to make sure that problems don't develop down the road.

Interviewer: And what caused that to happen? Is it something that the patient did or did it just happen?

Dr. Glotzbach: It can be both. There are risk factors including smoking and high blood pressure. There are some genetic conditions or familial patterns that can predispose people to have this problem. One of the biggest risk factors for aortic dissection is developing an aortic aneurysm, which is an enlarged area of the aorta which gets thinned out and weakens, so that's more susceptible to a dissection. But a lot of times these are just bad luck and this happens to someone who's never had an aortic problem before and this just kind of happens out of the blue, so it can be a devastating problem.

Interviewer: Are there any sort of warning symptoms that would come before the actual emergency event?

Dr. Glotzbach: Unfortunately, there are not a lot of warning symptoms. A lot of, you know, an aortic aneurysm is largely asymptomatic. High blood pressure can cause a bit of a warning, and then obviously people that have known aortic problems. But most people who have a dissection have no warning sign or nothing that suggests this is about to happen until it actually does happen.

Interviewer: All right and once . . . How is it diagnosed?

Dr. Glotzbach: Typically it's severe pain and so patients who have a dissection have severe chest pain or back pain or abdominal pain or all three, and a lot of times it could mimic a heart attack or other kind of acute problems. So most people know something is going wrong and they have severe pain, which then usually people come to the emergency department with the symptoms and then it's diagnosed from there with an imaging study.

Interviewer: And how do they get fixed in the short term and then what's their long term look like?

Dr. Glotzbach: Absolutely. So for a type A dissection like we talked about, that's a surgical emergency so those patients go to the operating room and we will replace the ascending aorta at least and sometimes more. Sometimes the aortic valve can be involved or the coronary arteries need to be reconstructed. Basically need to stabilize that first part of the aorta so that the blood flow to the brain and to the rest of the aorta is preserved. So that's a type A.

For a type B, which is involving the rest of the aorta, the most critical thing is to keep the patient's blood pressure under control and then to determine if there is any problem with blood flow to any of the other organs. So we look at blood flow to the liver, the gut and the legs, the kidneys, all those things. As long as there's blood flow to those organs, typically we can manage those patients medically.

Interviewer: And what does life look like after somebody has an aortic dissection? Likely I'm talking, you know . . .

Dr. Glotzbach: Long term.

Interviewer: Three to five years.

Dr. Glotzbach: Absolutely. So once we've stabilized after the initial event, then it becomes kind of a chronic disease that needs to be managed and watched closely like any chronic disease. And so the way we do that for aorta, number one, is blood pressure control so we have to . . . most patients are on one or multiple blood pressure medications and then we do long term follow up with imaging studies. And typically that's a CAT scan or a CT scan, which is a three-dimensional X-ray that gives us a very good picture of the aorta and tells us exactly what's going on.

And so we'll have the initial imaging from when it first happened and then we'll get every, between six months to a year or so and every year after that we'll get CT scans watching how that aorta is changing or not and if things start to change then sometimes we need to do procedures in the future and sometimes not, sometimes people just remain stable and we just keep watching them.

Interviewer: So what I'm getting is that it's something that could happen again to somebody who's had one.

Dr. Glotzbach: It could, and once you've had an aortic dissection your aorta's at risk for life and so this is something that is, you know, can be managed and stable and people can go on living with it but it's not something that will ever heal completely and so people just have to be aware that they need lifelong surveillance and I think that's where a true aortic program comes in where you have a dedicated team of physicians and nurses and radiologists and people that are used to watching these over long term so that we can pick up on problems as they begin to develop, before they turn into big problems, we can intervene.

Interviewer: And what about quality of life?

Dr. Glotzbach: I think that this is a very serious emergency. When these happen, they're life threatening and should be taken seriously and treated immediately at a hospital and so the quality of life after that, once you've stabilized and treated from the initial event, people can go on living normal lives and do almost anything that they want to do provided they have good follow up care and we keep an eye on things and make sure that that aorta remains stable and doesn't develop complications down the road.

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