title: Acute Aortic Dissection and Intramural Hematoma: A Systematic Review.
abstract: OBJECTIVE
  Acute aortic syndrome (AAS), a potentially fatal pathologic process within the aortic wall, should be suspected in patients presenting with severe thoracic pain and hypertension. AAS, including aortic dissection (approximately 90% of cases) and intramural hematoma, may be complicated by poor perfusion, aneurysm, or uncontrollable pain and hypertension. AAS is uncommon (approximately 3.5-6.0 per 100,000 patient-years) but rapid diagnosis is imperative as an emergency surgical procedure is frequently necessary.
  
  
  OBJECTIVE
  To systematically review the current evidence on diagnosis and treatment of AAS.
  
  
  METHODS
  Searches of MEDLINE, EMBASE, and the Cochrane Register of Controlled Trials for articles on diagnosis and treatment of AAS from June 1994 to January 29, 2016, were performed. Only clinical trials and prospective observational studies of 10 or more patients were included. Eighty-two studies (2 randomized clinical trials and 80 observational) describing 57,311 patients were reviewed.
  
  
  RESULTS
  Chest or back pain was the most commonly reported presenting symptom of AAS (61.6%-84.8%). Patients were typically aged 60 to 70 years, male (50%-81%), and had hypertension (45%-100%). Sensitivities of computerized tomography and magnetic resonance imaging for diagnosis of AAS were 100% and 95% to 100%, respectively. Transesophageal echocardiography was 86% to 100% sensitive, whereas D-dimer was 51.7% to 100% sensitive and 32.8% to 89.2% specific among 6 studies (n = 876). An immediate open surgical procedure is needed for dissection of the ascending aorta, given the high mortality (26%-58%) and proximity to the aortic valve and great vessels (with potential for dissection complications such as tamponade). An RCT comparing endovascular surgical procedure to medical management for uncomplicated AAS in the descending aorta (n = 61) revealed no dissection-related deaths in either group. Endovascular surgical procedure was better than medical treatment (97% vs 43%, P < .001) for the primary end point of "favorable aortic remodeling" (false lumen thrombosis and no aortic dilation or rupture). The remaining evidence on therapies was observational, introducing significant selection bias.
  
  
  CONCLUSIONS
  Because of the high mortality rate, AAS should be considered and diagnosed promptly in patients presenting with acute chest or back pain and high blood pressure. Computerized tomography, magnetic resonance imaging, and transesophageal echocardiography are reliable tools for diagnosing AAS. Available data suggest that open surgical repair is optimal for treating type A (ascending aorta) AAS, whereas thoracic endovascular aortic repair may be optimal for treating type B (descending aorta) AAS. However, evidence is limited by the paucity of randomized trials.
authors.affiliation: Division of Vascular Surgery, Department of Surgery, Columbia University Medical Center, New York, New York.
authors.forename: Firas F
authors.initials: FF
authors.lastname: Mussa
authors.affiliation: New York University School of Medicine, New York.
authors.forename: Joshua D
authors.initials: JD
authors.lastname: Horton
authors.affiliation: Division of Vascular Surgery, University of California-Los Angeles, Los Angeles.
authors.forename: Rameen
authors.initials: R
authors.lastname: Moridzadeh
authors.affiliation: New York University School of Medicine, New York.
authors.forename: Joseph
authors.initials: J
authors.lastname: Nicholson
authors.affiliation: Cardiovascular Surgery Department, IRCCS Policlinico San Donato University of Milan, Milan, Italy.
authors.forename: Santi
authors.initials: S
authors.lastname: Trimarchi
authors.affiliation: Division of Cardiology, Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor.
authors.forename: Kim A
authors.initials: KA
authors.lastname: Eagle
mesh_terms: D000208:Acute Disease; D000368:Aged; D000784:Aortic Dissection / Q000150:complications / Q000175:diagnosis* / Q000601:surgery; D001014:Aortic Aneurysm / Q000150:complications / Q000175:diagnosis* / Q000601:surgery; D001018:Aortic Diseases / Q000150:complications / Q000175:diagnosis* / Q000601:surgery; D001416:Back Pain / Q000209:etiology; D002637:Chest Pain / Q000209:etiology; D005338:Fibrin Fibrinogen Degradation Products / Q000032:analysis; D006406:Hematoma / Q000150:complications / Q000175:diagnosis* / Q000601:surgery; D006801:Humans; D006973:Hypertension / Q000150:complications; D008279:Magnetic Resonance Imaging; D008297:Male; D008488:Medical Illustration; D008875:Middle Aged; D064887:Observational Studies as Topic; D016032:Randomized Controlled Trials as Topic; D012680:Sensitivity and Specificity; D014057:Tomography, X-Ray Computed
chemical_list: D005338:Fibrin Fibrinogen Degradation Products; C036309:fibrin fragment D