Chest / Cardiac for Thursday, April 10th, 2025

History

A 17-year-old girl was found unresponsive after an unwitnessed fall at home. Upon arrival to the emergency department, she had a blood pressure of 240/110. She was categorized as a level 1 trauma and received the following CT traumagram. 

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Question

How is the aortic injury classified?

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Correct answer

Stanford Type B

Discussion

This patient has a Stanford type B aortic dissection, beginning in the descending thoracic aorta and extending into the abdominal aorta, including celiac and SMA origins with a chronic calcified and thrombosed proximal component and a non-thrombosed component distally.

Stanford type A dissection involves any portion of the ascending aorta, while Stanford type B dissection involves only the descending aorta. Traditionally, a type A dissection is managed surgically with either an open or endovascular graft placement, while type B dissection is managed medically, usually with anti-hypertensives. However, this dissection threatens the origins of the celiac trunk and superior mesenteric artery. To avoid bowel ischemia, this patient required an endovascular surgical repair of their aorta. 

The work-up for vasculitis and other underlying genetic and rheumatologic causes for dissection were negative. It is thought that this dissection is a result of long-standing, undiagnosed hypertension. On a 4 drug regimen, her systolic blood pressure was lowered to 150 mmHg. 

References

• Sayed A, Munir M, Bahbah EI. Aortic Dissection: A Review of the Pathophysiology, Management and Prospective Advances. Curr Cardiol Rev. 2021;17(4):e230421186875. doi:10.2174/1573403X16666201014142930
• Bartosz Rylski, Oliver Schilling, Martin Czerny, Acute aortic dissection: evidence, uncertainties, and future therapies, European Heart Journal, Volume 44, Issue 10, 7 March 2023, Pages 813–821, https://doi.org/10.1093/eurheartj/ehac757
• Levy D, Sharma S, Grigorova Y, Farci F, Le JK. Aortic Dissection. 2024 Oct 6. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan–. PMID: 28722992.