Aortic dissection repair at the Penn Aorta Center

Surgeon Kendall Lawrence, MD, reviews the diagnosis, types, physiology, causes, and surgical management of aortic dissection at the Penn Aorta Center.

January 1, 1901

Kendall Lawrence, MD

Aneurysms of the aorta occur as a result of dilation of the aorta and are a leading cause of aortic dissection. Dissection occurs when a tear within the aorta allows blood to siphon between the layers, leading to internal organ ischemia.

A related condition, aortic rupture, manifests as a complete tearing of the vessel. Most dissections occur in the ascending aorta (Type A).

Acute aortic dissections are catastrophic, life-threatening events that typically occur without warning in otherwise asymptomatic individuals.

For patients admitted to a hospital for acute treatment of thoracic aortic aneurysm and dissection, or TAAD, the observed 30-day mortality ranges from 39-49%. Moreover, studies suggest that only a minority of verified cases are accurately diagnosed at first presentation.

For individuals who never reach a hospital, the death rate can reach 50% in the first 48 hours after symptom onset.

Not all aortic dissections are acute, however. Chronic, or non-traumatic dissection, defined as a dissection present for more than 2 weeks, has a slightly better prognosis than acute dissection. Management of these patients may involve surgery if the dissection type and location is reparable. Long-term follow-up after surgery is required to monitor for re-injury and increasing dilation, among other risks.

Aortic screening and preventative measures

Screening for aortic aneurysm (the leading risk factor for dissection) is complicated by the asymptomatic character of aortic dilation.

Thus, with the exception of individuals with a known genetic predisposition to dilation and dissection as a result of the heritable connective tissue syndromes (e.g., Marfan, Loeys-Dietz), the majority of aortic dilations and aneurysms are diagnosed as incidental findings. For these individuals, management measures include long-term monitoring of the aortic diameter, blood pressure control, and surgery when aortic dilation reaches 5.5 cm.

In an episode of Penn Medicine Physician Interviews, aortic surgery specialist Kendall Lawrence, MD, discusses the diagnosis, physiology, symptomatology, types, and causes of acute aortic dissection. She also describes the management of dissection at the Penn Aorta Center, including monitoring and surgical repair of the ascending aorta and aortic arch.

Direct-to-OR program at Penn Aorta Center

“Over the past two decades at Penn we built a robust direct-to-OR program for patients presenting with acute aortic emergencies,” Dr. Lawrence explains. “We get a call from any number of outside hospitals or outside referring's, and they're able to share the CAT scans with us for us to review 24 hours a day over the phone.”

If the clinical team agrees with the diagnosis of an acute aortic dissection, Dr. Lawrence says, “We will bring the patient directly from wherever they are to our operating rooms.”

Lifelong aortic monitoring program and early detection

The Penn Aorta Center has unique infrastructure in place to track patients with aortic dissection through a lifelong aortic surveillance—among the longest-running programs of its kind.

Dr. Lawrence explains, “We enter patients into active surveillance programs that involve regular CT screenings and meetings with our aortic team.”

The Center’s advanced practice providers follow current and past dissection patients—and proactively follow family members of patients who have had aortic surgery—to detect the presence of aneurysm at an early rate.

“We know that patients that present with thoracic aortic aneurysms, about 20-to-30% of those patients are going to have a genetic cause to their aneurysms,” Dr. Lawrence says.

“At Penn, we have a robust genetic medicine program,” she continues. “And, for patients that present particularly at a young age with no other identifiable risk factors and a family history of aortic aneurysms, we offer genetic testing.”

Kendall Lawrence, MD, is an Assistant Professor of Surgery at the Penn Heart and Vascular Center. She sees patients at the Perelman Center for Advanced Medicine.