Dissecting Aortic Dissection: How this fatal condition can manifest itself as heart disease

By Joseph Lombardi, M.D.

You probably remember the tragic death of actor John Ritter in 2003. Recently, his family partnered with the Thoracic Aortic Disease (TAD) Coalition to shed light on the condition that took his life: aortic dissection. In addition to TAD Coalition’s “Ritter Rules,” which focus on recognizing, treating and preventing the condition, the American Heart Association and American College of Cardiology also released new guidelines designed to prevent unnecessary deaths.  Aortic dissection occurs when the wall of the aorta, the body’s main blood vessel, splits and blood flows in the wall of the aorta.  That extra channel of blood flow then travels down the length of the aorta and can rupture the vessel or shut down other vital blood vessels causing obstruction of blood-flow to vital organs.  Aortic dissection generally affects one in 10,000 Americans and is usually more prevalent in patients with high blood pressure or hypertension.

The biggest complaint patients describe is a tearing pain in their back that doesn’t go away.  The pain is a very uncomfortable and patients tend to seek emergency rooms for relief as they usually know something is very wrong.  Aortic dissection can also cause chest pain, arm pain and other types of pains that are commonly associated with a heart attack.  Emergency room physicians frequently have to distinguish if a patient is having a heart attack or an aortic dissection as the symptoms are so similar.  In fact, John Ritter was misdiagnosed with a heart attack.

The current treatments available are open chest surgery for dissections closest to the heart (type A) or placing an endograft, relining the aortic wall.  Although this form of therapy is still being investigated, most vascular surgeons who perform this procedure would agree that placing an endograft more quickly restores blood flow to obstructed blood vessels than open surgery, and is a much less demanding operation on a patient who has already gone under a significant trauma from the dissection process.

The issue with aortic dissection is that it can cause so many different problems, all requiring potentially different treatments. Most of the time, patients with a form of aortic dissection called type B aortic dissection can be treated medically.  In fact, more than 80 percent of these patients are treated medically and tend to recover in time.  But, an unfortunate 20 percent of patients who experience type B aortic dissection can develop a ruptured aorta, persistent back pain and obstruction to any one of the blood vessels that the aorta supplies.  Various presentations may arise depending upon which blood vessel the aortic dissection compromised.

The biggest challenge for traditional open-operative surgery, during which the patients’ chest is opened up and a new graft sewn in place, is simply repairing the aortic wall because the wall is so thin and inflamed.  The procedure is comparable to sewing wet pieces of tissue paper together, because it can easily tear.  Due to these challenges, surgeons find operating on a fresh aortic dissection very difficult.

I am currently working on the STABLE trial, the first trial designed to focus on complicated type B aortic dissections and to evaluate a device that seals the initial tear causing the dissection and then supports the wall of the aorta to enhance blood flow to all the different blood vessels, including your legs.  The system is specifically designed for aortic dissection and uses an endovascular approach which is minimally invasive. We are hopeful to show dramatic differences compared to standard open surgical options.

Joseph Lombardi, M.D. is the Head of the Division of Vascular Surgery at Cooper University Hospital, N. J.