Aortic dissection: Indecision and delays are the parents of physiological failure

Abstract

Aortic dissection: Indecision and delays are the parents of physiological failureA recent publication in a national newspaper in the UK reported the sudden and unexpected death of an apparently fit and well 50year-old female returning from holiday after complaining of chest pain as the plane began its descent to land (Raemason, 2024). The cause of death was an acute aortic dissection (AD), an infrequent yet potentially catastrophic disorder affecting the abdominal and thoracic aortic segments. The coroner's inquest concluded that the death was probably avoidable due to significant delays of up to 16 h prior to operative intervention being attempted. In this editorial, we briefly examine the integrative physiology and anatomical-surgical challenges and controversies associated with this emergent and potentially deadly medical condition.A tear in the aortic intima is the cause of AD, which results in a blood column penetrating the medial layer of the aorta causing a 'hydraulic endarterectomy' , creating a septum of medial and intimal aortic tissue that separates the aorta's true and false lumens (Figure 1a). AD has an estimated incidence of between 4.5 and 7 per 100,000 (Booth, 2023) and if left untreated, mortality can be as high as 90% after 3 months, with acute mortality estimated between 1% and 2% per hour after the onset of symptoms (Kouchoukos & Dougenis, 1997;Tsai et al., 2005).Clinical diagnosis of AD is challenging and remains controversial, complicated by its modest prevalence, lack of sensitive-specific biomarkers and highly variable clinical course with a relatively high number of atypical presentations (Banceu et al., 2024). In addition to established risk factors, with severe chronic hypertension the most common, sudden onset chest/aortic pain is a common symptom that is typically sharp, strong and tearing, often radiating towards the destination of the lesion's advancement in accordance with the implicated aortic branches (Erbel et al., 2014). A 12-lead electrocardiogram, chest radiography and diagnostic biomarkers (e.g., systemic concentrations of cardiac troponin and D-dimer) help exclude differential diagnoses of pulmonary embolism or acute coronary syndrome. In the emergency room, a computed tomography aortogram is the favoured imaging diagnostic modality of choice in light of widespread accessibility and comprehensive anatomical evaluation of the aorta and branch vessels (Vardhanabhuti et al., 2016). Postcontrast computed tomography (CT) of the whole (thoracic and abdominal) aorta is recommended in high-risk patients including those This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.