Skip to main content
SpringerLink
Log in

Characterization of Aortic Dissection: What the Radiologist Needs to Know

  • Cardiac Computed Tomography (S Achenbach and T Villines, Section Editor)
  • Published:
Current Cardiovascular Imaging Reports Aims and scope Submit manuscript

Abstract

Evaluation of acute aortic dissection by computed tomography angiography provides detailed characterization of this disease beyond the Stanford classification. Recent publications based on large patient registries and other sources have identified morphological characteristics that impact patient prognosis, and advanced understanding of both the incidence and demographics of this disease. This article reviews the recent literature and discusses the importance of imaging findings, such as aortic/false lumen diameter, signs of organ malperfusion, false lumen thrombosis, and characterization of intimal tears. The associated entity acute intramural hematoma is discussed, as well as imaging features that predict adverse outcomes. Familiarity with these imaging characteristics maximizes the utility of radiographic evaluation in this disease.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8
Fig. 9
Fig. 10
Fig. 11
Fig. 12
Fig. 13
Fig. 14

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Mehta RH, Suzuki T, Hagan PG, Bossone E, Gilon D, Llovet A, et al. Predicting death in patients with acute type A aortic dissection. Circulation. 2002;105:200–6.

    Article  PubMed  Google Scholar 

  2. Suzuki T, Mehta RH, Ince H, Nagai R, Sakomura Y, Weber F, et al. Clinical profiles and outcomes of acute type B aortic dissection in the current era: lessons from the International Registry of Aortic Dissection (IRAD). Circulation. 2003;108:II312–7.

    Article  PubMed  Google Scholar 

  3. Howard DP, Banjee A, Fairhead JF, Perkins J, Silver LE, Rothwell PM. Oxford Vascular Study. Population-based study of incidence and outcome of acute aortic dissection and premorbid risk factor control: 10-year results from the Oxford Vascular Study. Circulation. 2013;127:2031–7. This recent population-based study furthers knowledge of the incidence and risk factors for aortic dissection by including out-of-hospital cases.

    Article  PubMed  Google Scholar 

  4. Hagan PG, Nienaber CA, Isselbacher EM, et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA. 2000;283(7):897–903.

    Article  CAS  PubMed  Google Scholar 

  5. Pretre R, Von Segesser LK. Aortic dissection. Lancet. 1997;349:1461–4.

    Article  CAS  PubMed  Google Scholar 

  6. Bickerstaff LK, Palrolero PC, Hollier LH, et al. Thoracic aortic aneurysms: a population-based study. Surgery. 1982;92:1103–8.

    CAS  PubMed  Google Scholar 

  7. Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey Jr DE, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation. 2010;121:e266–369.

    Article  PubMed  Google Scholar 

  8. Hayter RG, Rhea JT, Small A, Tafazoli FS, Novelline RA. Suspected aortic dissection and other aortic disorders: multi-detector row CT in 373 cases in the emergency setting. Radiology. 2006;238:841–52.

    Article  PubMed  Google Scholar 

  9. Clouse WD, Hallett Jr JW, Schaff HV, Spittell PC, Rowland CM, Ilstrup DM, et al. Acute aortic dissection: population-based incidence compared with degenerative aortic aneurysm rupture. Mayo Clin Proc. 2004;79:176–80.

    Article  PubMed  Google Scholar 

  10. Tsai TT, Trimarchi S, Nienaber CA. Acute aortic dissection: perspectives from the International Registry of Acute Aortic Dissection. Eur J Endovasc Surg. 2009;37:149–59.

    Article  CAS  Google Scholar 

  11. Tolenaar JL, van Keulen JW, Jonker FH, van Herwaarden JA, Verhagen HJ, Moll FL, et al. Morphologic predictors of aortic dilatation in type B aortic dissection. J Vasc Surg. 2013;58:1220–5. This recent report analyzes a number of morphological features for prediction of a key question in management of type B dissection: which patients will develop aortic enlargement and require intervention?.

    Article  PubMed  Google Scholar 

  12. Jonker FH, Trimarchi S, Muhs BE, Rampoldi V, Montgomery DG, Froehlich JB, et al. The role of age in complicated acute type B aortic dissection. Ann Thorac Surg. 2013;96:2129–34.

    Article  PubMed  Google Scholar 

  13. Tanaka A, Sakakibara M, Ishii H, Hayashida R, Jinno Y, Okumura S, et al. Influence of the false lumen status on clinical outcomes in patients with acute type B aortic dissection. J Vasc Surg. 2014;59:321–6.

    Article  PubMed  Google Scholar 

  14. Trimarchi S, Eagle KA, Nienaber CA, Rampoldi V, Jonker FH, De Vincentis C, et al. Role of age in acute type A aortic dissection outcome: report from the International Registry of Acute Aortic Dissection (IRAD). J Thorac Cardiovasc Surg. 2010;140:784–9.

    Article  PubMed  Google Scholar 

  15. Piccardo A, Le Guyader A, Regesta T, Gariboldi V, Zannis K, Tapia M, et al. Octogenarians with uncomplicated acute type A aortic dissection benefit from emergency operation. Ann Thorac Surg. 2013;96:851–6. A recent retrospective study finding that surgery is beneficial in type A dissection in patients over 80 years old, except when complications (neurological deficit, mesenteric ischemia, need for CPR) occur at presentation.

    Article  PubMed  Google Scholar 

  16. Rylski B, Suedkamp M, Beyersdorf F, Nitsch B, Hoffman I, Blettner M, et al. Outcome after surgery for acute aortic dissection type A in patients over 70 years; data analysis from the German Registry for Acute Aortic Dissection Type A (GERAADA). Eur J Cardiothorac Surg. 2011;40:435–40.

    PubMed  Google Scholar 

  17. Daily PO, Trueblood HW, Stinson EB, Wuerflein RD, Shumway NE. Management of acute aortic dissections. Ann Thorac Surg. 1970;10:237–47.

    Article  CAS  PubMed  Google Scholar 

  18. Schernthaner RE, Stadler A, Beitzke D, Homolka P, Weber M, Lammer J, et al. Dose modulated retrospective ECG-gated versus non-gated 64-row CT angiography of the aorta at the same radiation dose: comparison of motion artifacts, diagnostic confidence and signal-to-noise-ratios. Eur J Radiol. 2012;81:e585–90.

    Article  PubMed  Google Scholar 

  19. Vernhet H, Serfaty JM, Serhal M, McFadden E, Bonnefoy E, Adeleine P, et al. Abdominal CT angiography before surgery as a predictor of postoperative death in acute aortic dissection. AJR Am J Roentgenol. 2004;182:875–9.

    Article  PubMed  Google Scholar 

  20. Di Eusanio M, Trimarchi S, Patel HJ, Hutchison S, Suzuki T, Peterson MD, et al. Clinical presentation, management, and short-term outcome of patients with type A acute dissection complicated by mesenteric malperfusion: observations from the International Registry of Aortic Dissection. J Thorac Cardiovasc Surg. 2013;145:385–90.

    Article  PubMed  Google Scholar 

  21. Gaxotte V, Cocheteux B, Haulon S, Vincentelli A, Lions C, Koussa M, et al. Relationship of intimal flap position to endovascular treatment of malperfusion syndromes in aortic dissection. J Endovasc Ther. 2003;10:719–27.

    Article  PubMed  Google Scholar 

  22. Williams DM, Lee DY, Hamilton BH, Marx MV, Narasimham DL, Kazanjian SN, et al. The dissected aorta: percutaneous treatment of ischemic complications – principles and results. J Vasc Interv Radiol. 1997;8(4):605–25.

    Article  CAS  PubMed  Google Scholar 

  23. Vedantham S, Picus D, Sanchez LA, Braverman A, Moon MR, Sundt 3rd T, et al. Percutaneous management of ischemic complications in patients with type B aortic dissection. J Vasc Interv Radiol. 2003;14:181–94.

    Article  PubMed  Google Scholar 

  24. Kato M, Bai H, Sato K, Kawamoto S, Kanedko M, Ueda T, et al. Determining surgical indications for acute type B dissection based on enlargement of aortic diameter during the chronic phase. Circulation. 1995;92(9 Suppl):II107–12.

    Article  CAS  PubMed  Google Scholar 

  25. Marui A, Mochizuki T, Mitsui N, Koyama T, Kimura F, Horibe M. Toward the best treatment for uncomplicated patients with type B acute aortic dissection: a consideration for sound surgical indication. Circulation. 1999;100(19 Suppl):II275–80.

    CAS  PubMed  Google Scholar 

  26. Kudo T, Mikamo A, Kurazumi H, Suzuki R, Morikage N, Hamano K. Predictors of late aortic events after Stanford type B acute aortic dissection. J Thorac Cardiovasc Surg. 2013. doi:10.1016/j.jtcvs.2013.07.047.

    PubMed  Google Scholar 

  27. Jonker FH, Trimarchi S, Rampoldi V, Patel HJ, O’Gara P, Peterson MD, et al. Aortic expansion after acute type B aortic dissection. Ann Thorac Surg. 2012;94:1223–9. This recent report from the sizable IRAD identifies both clinical and imaging characteristics associated with subsequent aortic growth in patients presenting with acute type B aortic dissection.

    Article  PubMed  Google Scholar 

  28. Ueki C, Sakaguchi G, Shimamoto T, Komiya T. Prognostic factors in patients with uncomplicated acute type B aortic dissection. Ann Thorac Surg. 2014;97:767–73.

    Article  PubMed  Google Scholar 

  29. Tsai TT, Evangelista A, Nienaber CA, Trimarchi S, Sechtem U, Fattori R, et al. Long-term survival in patients presenting with type A acute aortic dissection: insights from the International Registry of Acute Aortic Dissection (IRAD). Circulation. 2006;114:I350–I1356.

    Article  PubMed  Google Scholar 

  30. Song JM, Kim HS, Song JK, Kang DH, Hong MK, Kim JJ, et al. Usefulness of the initial noninvasive imaging study to predict the adverse outcomes in the medical treatment of acute type A aortic intramural hematoma. Circulation. 2003;108:II324–8.

    Article  PubMed  Google Scholar 

  31. Song JK, Yim JH, Ahn JM, Kim DH, Kang JW, Lee TY, et al. Outcome of patients with acute type A aortic intramural hematoma. Circulation. 2009;120:2046–52.

    Article  PubMed  Google Scholar 

  32. Sawaki S, Hirate Y, Ashida S, Takanohashi A, Yagami K, Usui M. Clinical outcomes of medical treatment of acute type A intramural hematoma. Asian Cardiovasc Thorac Ann. 2010;18:354–9.

    Article  PubMed  Google Scholar 

  33. Watanabe S, Hanyu M, Arai Y, Nagasawa A. Initial medical treatment for acute type A intramural hematoma and aortic dissection. Ann Thorac Surg. 2013;96:2142–6.

    Article  PubMed  Google Scholar 

  34. Ahmed S, Zimmerman SL, Johnson PT, Lai H, Kawamoto S, Horton KM, et al. MDCT interpretation of the ascending aorta with semiautomated measurement software: improved reproducibility compared with manual techniques. J Cardiovasc Comput Tomogr. 2014;8:108–14.

    Article  PubMed  Google Scholar 

  35. Lu TL, Rizzo E, Marques-Vidal PM, Segesser LK, Dehmeshki J, Qanadli SD. Variability of ascending aorta diameter measurements as assessed with electrocardiography-gated multidetector computerized tomography and computer assisted diagnosis software. Interact Cardiovasc Thorac Surg. 2010;10:217–21.

    Article  PubMed  Google Scholar 

  36. Tsai TT, Evangelista A, Nienaber CA, Myrmel T, Meinhardt G, Cooper JV, et al. Partial thrombosis of the false lumen in patients with acute type B aortic dissection. N Engl J Med. 2007;357:349–59.

    Article  CAS  PubMed  Google Scholar 

  37. Trimarchi S, Tolenaar JL, Jonker FH, Murray B, Tsai TT, Eagle KA, et al. Importance of false lumen thrombosis in type B aortic dissection prognosis. J Thorac Cardiovasc Surg. 2013;145(3 Suppl):S208–12. This recent follow-up study supports the observations of Tsai et al. in 2007 that partially thrombosed false lumen is associated with worse prognosis in type B dissection.

    Article  PubMed  Google Scholar 

  38. Sueyoshi E, Sakamoto I, Uetani M. Growth rate of affected aorta in patients with type B partially closed aortic dissection. Ann Thorac Surg. 2009;88:1251–7.

    Article  PubMed  Google Scholar 

  39. Chung JW, Elkins C, Sakai T, Kato N, Vestring T, Semba CP, et al. True-lumen collapse in aortic dissection: part I. Evaluation of causative factors in phantoms with pulsatile flow. Radiology. 2000;214(1):87–98.

    Article  CAS  PubMed  Google Scholar 

  40. Chung JW, Elkins C, Sakai T, Kato N, Vestring T, Semba CP, et al. True-lumen collapse in aortic dissection: part II. Evaluation of treatment methods in phantoms with pulsatile flow. Radiology. 2000;214(1):99–106.

    Article  CAS  PubMed  Google Scholar 

  41. Tsai TT, Schlicht MS, Khanafer K, Bull JL, Valassis DT, Williams DM, et al. Tear size and location impacts false lumen pressure in an ex vivo model of chronic type B aortic dissection. J Vasc Surg. 2008;47:844–51.

    Article  PubMed  Google Scholar 

  42. Tolenaar JL, van Keulen JW, Trimarchi S, Jonker FH, van Herwaarden JA, Verhagen HJ, et al. Number of entry tears is associated with aortic growth in type B dissections. Ann Thorac Surg. 2013;96:39–42.

    Article  PubMed  Google Scholar 

  43. Khoynezhad A, Walot I, Kruse MJ, Rapae T, Donayre CE, White RA. Distribution of intimomedial tears in patients with type B aortic dissection. J Vasc Surg. 2010;52:562–8.

    Article  PubMed  Google Scholar 

  44. Loewe C, Czerny M, Sodeck GH, et al. A new mechanism by which an acute type B aortic dissection is primarily complicated, becomes complicated, or remains uncomplicated. Ann Thorac Surg. 2012;93:1215–22.

    Article  PubMed  Google Scholar 

  45. Nienaber CA, Kische S, Zeller T, Rehders TC, Schneider H, Lorenzen B, et al. Provisional extension to induce complete attachment after stent graft placement in type B aortic dissection: the PETTICOAT concept. J Endovasc Ther. 2006;13:738–46.

    Article  PubMed  Google Scholar 

  46. Steingruber IE, Chemelli A, Glodny B, Hugl B, Bonatti J, Hiemetzbeger R, et al. Endovascular repair of acute type B aortic dissection: mid term results. J Endovasc Ther. 2008;15:150–60.

    Article  PubMed  Google Scholar 

  47. Melissano G, Bertoglio L, Rinaldi E, Civilini E, Tshomba Y, Kahlberg A, et al. Volume changes in aortic true and false lumen after the “PETTICOAT” procedure for type B aortic dissection. J Vasc Surg. 2012;55:641–51.

    Article  PubMed  Google Scholar 

  48. Tolenaar JL, Harris KM, Upchurch Jr GR, Evangelista A, Moll FL, di Eusanio M, et al. The differences and similarities between intramural hematoma of the descending aorta and acute type B dissection. J Vasc Surg. 2013;58:1498–504.

    Article  PubMed  Google Scholar 

  49. Akutsu K, Nejima J, Kiuchi K, Sasaki K, Ochi M, Tanaka K, et al. Effects of the patent false lumen on the long-term outcome of type B acute aortic dissection. Eur J Cardiothorac Surg. 2004;26:359–66.

    Article  PubMed  Google Scholar 

  50. Harris KM, Braverman AC, Eagle KA, Woznicki EM, Pyeritz RE, Myrmel T, et al. Acute aortic intramural hematoma: an analysis from the International Registry of Acute Aortic Dissection. Circulation. 2012;126(11 Suppl):S91–6. This report from the IRAD registry details the differences in patient presentation, demographics, and outcomes between patients with acute intramural hematoma and those with acute dissection.

    Article  PubMed  Google Scholar 

  51. Sueyoshi E, Matsuoka Y, Sakamoto I, Uetani M, Hayashi K, Narimatsu M. Fate of intramural hematoma of the aorta: CT evaluation. J Comput Assist Tomogr. 1997;21:931–8.

    Article  CAS  PubMed  Google Scholar 

  52. Kitai T, Kaji S, Yamamuro A, Tani T, Kinoshita M, Ehara N, et al. Impact of new development of ulcer-like projection on clinical outcomes in patients with type B aortic dissection with closed and thrombosed false lumen. Circulation. 2010;122:S74–80.

    Article  PubMed  Google Scholar 

  53. Wu MT, Wang YC, Huang YL, Chang RS, Li SC, Yang P, et al. Intramural blood pools accompanying aortic intramural hematoma: CT appearance and natural course. Radiology. 2011;258:705–13.

    Article  PubMed  Google Scholar 

  54. Schlatter T, Auriol J, Marcheix B, Lebbadi M, Marachet MA, Dang-Tran KD, et al. Type B intramural hematoma of the aorta: evolution and prognostic value of intimal erosion. J Vasc Interv Radiol. 2011;22:533–41. This retrospective study details the difference in prognostic implications between ulcer-like projections and intramural blood pools in patients with type B intramural hematoma.

    Article  PubMed  Google Scholar 

  55. Miyahara S, Mukohara N, Fukuzumi M, Morimoto N, Murakami H, Nakagiri K, et al. Long-term follow-up of acute type B aortic dissection: ulcer-like projections in thrombosed false lumen play a role in late aortic events. J Thorac Cardiovasc Surg. 2011;142:25–31.

    Article  Google Scholar 

  56. Williams DM, Cronin P, Dasika N, Upchurch Jr GR, Patel HJ, Deeb MG, et al. Aortic branch artery pseudoaneurysms accompanying aortic dissection. Part 1: pseudoaneurysm anatomy. J Vasc Interv Radiol. 2006;17:765–71.

    Article  PubMed  Google Scholar 

  57. Macura KJ, Corl FM, Fishman EK, Bluemke DA. Pathogenesis in acute aortic syndromes: aortic dissection, intramural hematoma, and penetrating atherosclerotic aortic ulcer. AJR Am J Roentgenol. 2003;181:309–16.

    Article  PubMed  Google Scholar 

  58. Johnson PT, Corl FM, Black JH, Fishman EK. The elephant trunk procedure for aortic aneurysm repair: an illustrated guide to surgical technique with CT correlation. AJR Am J Roentgenol. 2011;197:W1052–9.

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

The authors thank Frank M. Corl for preparing the illustrations in this paper.

Sources of Financial Support

None.

Compliance with Ethics Guidelines

ᅟ

Conflict of Interest

Matthew J. Kruse, Elliot K. Fishman, and Stefan L. Zimmerman declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Author information

Authors and Affiliations

  1. Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, 601 N. Caroline Street, Baltimore, MD, 21287, USA

    Matthew J. Kruse, Elliot K. Fishman & Stefan L. Zimmerman

Authors
  1. Matthew J. Kruse
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Elliot K. Fishman
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Stefan L. Zimmerman
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Stefan L. Zimmerman.

Additional information

This article is part of the Topical Collection on Cardiac Computed Tomography

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Kruse, M.J., Fishman, E.K. & Zimmerman, S.L. Characterization of Aortic Dissection: What the Radiologist Needs to Know. Curr Cardiovasc Imaging Rep 7, 9273 (2014). https://doi.org/10.1007/s12410-014-9273-1

Download citation

  • Published:

  • DOI: https://doi.org/10.1007/s12410-014-9273-1

Keywords

Search

Navigation