Some Aortic Dissections Can Be Treated Without Open Surgery

As part of Vascular Disease Awareness Month, doctors at Baptist Health’s Miami Cardiac & Vascular Institute are shining a spotlight on aortic aneurysms and, more specifically, what happens when one dissects or ruptures.

Aortic dissections are rare, with an estimated five to 30 cases per million people, according to the Cardiovascular Diagnostic Therapy Journal. The U.S. Centers for Disease Control & Prevention (CDC) says that aortic aneurysms or aortic dissections were the cause of 9,904 deaths in 2019, nearly 60 percent of them men. The popular TV actor John Ritter died of an undetected aortic dissection in 2003, at the age of 54.

Doctors describe an aortic aneurysm as a balloon-like bulge in the aorta, the large artery that carries blood from the heart through the chest and torso. A thoracic aortic aneurysm happens in the chest, while the more common abdominal aortic aneurysm happens below the chest.

Sometimes – often as a result of the patient’s chronic high blood pressure – the force of blood pumping can create fatigue in the artery wall, which can eventually cause the wall to tear. Blood surges through the tear and separates, or dissects, the inner and middle layers of the aorta. Or, even worse, the aneurysm can rupture completely, which leads to bleeding inside the body. Both conditions can be fatal if not treated quickly, doctors say.

“The aorta has three layers – the intima, or inner layer; the media, or middle layer; and the adventitia, or outer wall,” explains Andrew Niekamp, M.D., interventional radiologist with Miami Cardiac & Vascular Institute. “A tear in the intima allows blood to trap and collect between it and the media. This can weaken the adventitia and end up dissecting into other vessels supplied by the aorta and affecting those respective organs.”

Ripping back pain a common symptom

People suffering an aortic dissection will know immediately that something is wrong, Dr. Niekamp notes. “Many patients describe it as a ‘ripping’ or ‘tearing’ back pain, sometimes accompanied by diaphoresis, or excessive sweating,” he says. “People with a thoracic aortic dissection may feel chest pain, and those with an abdominal aortic dissection may feel pain in their abdomen, but the ripping back pain is by far the most common symptom.”

Aortic ruptures are rarer but even more serious, Dr. Niekamp says, adding that most patients never even make it to the hospital. “Don’t dismiss the symptoms. Seek emergency care as soon as possible,” he advises.

Treatment protocols depend on dissection type

Most often, an aortic aneurysm or dissection is discovered when a patient undergoes imaging – a chest scan or an MRI, for example – for some other condition that’s being evaluated. At that point, Dr. Niekamp notes, an interventional radiologist would need to determine if it’s something that can be monitored or if it requires surgical intervention,

Doctors use the Stanford Classification System as a guide for treating aortic dissections, Dr. Niekamp says. A Stanford Type A dissection involves the ascending aorta which feeds the three main blood vessels supplying the upper extremities and head and neck area. “That’s valuable territory and a dissection here requires immediate surgical repair,” he explains. “Not only is your brain at risk but also the coronary arteries providing blood to your heart.”

Surgically repairing a Type A dissection is complex and typically requires a large incision in the chest, says Dr. Niekamp, adding that patients need extensive recovery time and cardiac rehabilitation following surgery. But the long-term prognosis for patients who’ve had an aortic dissection repair is “quite favorable,” he says. “We’ve had a number of patients here at Miami Cardiac & Vascular Institute who have presented with Type A dissections and they’ve done extremely well.”

Risk factors for aortic dissection

The CDC says that chronic hypertension, or high blood pressure, is a leading cause of aortic dissections, noting that “diseases and unhealthy behaviors that damage your heart and blood vessels also increase your risk for aortic aneurysm.” Dr. Niekamp says that, for less serious Type B dissections, the mainstay of treatment is blood pressure control.

Smoking is the most important behavior related to aortic aneurysm, the CDC says, accounting for roughly 75 percent of all abdominal aortic aneurysms. “Smoking weakens the aortic wall and causes the aorta to dilate, which can lead to dissection,” explains Dr. Niekamp. “Also, certain drugs – cocaine, for example – can produce rapid spikes in blood pressure, which can cause dissection.”

Other risk factors include a pre-existing aortic aneurysm, an aortic valve defect, hardening of the arteries or a narrowing of the aorta at birth, the CDC says. Dr. Niekamp adds that people who have a family history of aortic aneurysms, or certain inherited connective tissue disorders such as Marfan syndrome and Ehlers-Danlos syndrome, are also at increased risk.

Maximizing medications to increase your cardiovascular health can be effective in reducing your risk for an aortic dissection, Dr. Niekamps says, adding that medications alone aren’t the answer. “Lifestyle modifications are required, too,” he says. “You need to address any other risk factors you may have through smoking cessation, weight management, blood pressure control, cholesterol management or diabetes management. These are all extremely important.”

Screening recommended for older men

Because they are so rare, there is no official government-sponsored screening program for aortic aneurysms. Even so, the U.S. Preventive Services Task Force recommends that men 65 to 75 years old who have ever smoked should get an ultrasound screening for abdominal aortic aneurysms, even if they have no symptoms.

If you should be diagnosed with an aortic aneurysm, or if you were to suffer an aortic dissection or rupture, Dr. Niekamp says that Miami Cardiac & Vascular Institute physicians are specially trained and have access to the most advanced technology for diagnosing and treating these and other highly complex vascular diseases.

Type B dissections can often be repaired through endovascular treatment, Dr. Niekamp adds, sparing the patient from having to endure major open surgery. “Endovascular is actually the preferred treatment,” he says. “The outcomes are favorable and, more importantly, patients experience far less discomfort and much shorter recovery times.”