Pressure Points

By Peter Galvin, MD

The word dissection has several meanings, including opening and examining organic tissues (i.e., a fetal pig) and a tear in the wall of a high-pressure artery, like the carotid or aortic artery. A carotid artery dissection can cause a stroke while an aortic dissection can lead to a heart attack or stroke. Both can lead to sudden death, and therefore are considered medical emergencies. Also, both can be caused by years of uncontrolled, untreated high blood pressure which causes the arterial walls to thin out. Hypertension usually has no symptoms, at least in the early stages, which is why it is known as the “silent killer.” Uncontrolled high blood pressure is often found during a routine medical exam, which is one of the reasons why regular check-ups are so important.

The aorta begins at the aortic valve of the heart and travels upward. This section is known as the ascending aorta. The coronary arteries branch off from the base of the ascending aorta. At the top of its ascent, the aorta gives rise to three main arteries that supply blood to the head, arms, and torso. This is known as the aortic arch. Then the aorta travels downward, supplying blood to the abdomen and lower body. This is known as the descending aorta. An aortic dissection usually causes sudden sharp, and severe pain in the neck, chest, back, or abdomen, depending upon where the tear occurs. After the tear occurs, blood pools inside the aortic wall, causing blood clots that narrow the blood flow within the aorta, or the pooled blood can cause a bulge in the wall or an aortic aneurysm. A burst aneurysm is usually fatal.

Ascending aortic dissection can cause a heart attack, stroke, or dysfunction of the aortic valve, which leads to heart failure. A tear in the descending aorta may reduce flow to the intestines, abdominal organs, and the legs. Aortic dissections occur in five to 10 per 100,000 people each year and are more common in males and older individuals. Risk factors include high blood pressure, atherosclerosis (plaque buildup inside the aorta), preexisting aortic aneurysm, bicuspid aortic valve (two leaflets instead of three), cocaine use, traumatic chest injury, certain genetic diseases (like Marfan and Turner syndromes), and certain connective tissue diseases (like Ehlers-Danlos syndrome). An aortic dissection can be imaged using CT, MRI, or echocardiography. Reducing the patient’s blood pressure immediately is vital. Ascending aortic dissections usually require emergency surgery. Descending ones can be treated with medications but often require surgical correction if they disrupt blood flow to vital organs, such as the kidneys or intestines.

Surgery can either be open or endovascular (done using a catheter). Open surgery to repair an ascending dissection requires open heart surgery, use of a synthetic graft, and often aortic valve replacement. Endovascular repair inserts a graft via a catheter inserted at the groin. After repair of an aortic dissection, patients must be closely monitored to ensure their blood pressure is well controlled and will require regularly scheduled aortic imaging studies.

If you haven’t been to your doctor for a checkup in a while, schedule one today to check your blood pressure, especially if you are 45 years of age or older. Your life may depend on it.

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