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A dissecção aórtica aguda é uma condição potencialmente letal, com morbimortalidade significativa e taxa de mortalidade de 1-2% a cada hora se não tratada, necessitando de diagnóstico rápido e intervenção precoce. O objetivo deste trabalho é rever a dissecção aórtica aguda e o estado da arte no seu diagnóstico e tratamento. Foi selecionada a informação considerada relevante na literatura disponível e em artigos científicos publicados nos últimos 5 anos, na língua inglesa, pesquisados no motor de busca “PubMed”.
O sintoma mais comum é a dor intensa de início súbito, descrita como “sensação de rasgadura ou esfaqueamento”. Após a anamnese, exame físico e exames laboratoriais de rotina, novos biomarcadores têm surgido com potencial papel diagnóstico. Os mais promissores incluem D-dímeros, metaloproteinases da matriz extracelular, cadeia pesada de miosina, fragmentos solúveis de elastina, endotelina e fator de transformação do crescimento beta. A radiografia de tórax pode indiciar a condição e o eletrocardiograma sugere possíveis complicações agudas. O gold-standard imagiológico para o diagnóstico é a tomografia computadorizada por multidetetores, embora a ressonância magnética e ecografias transtorácica e transesofágica tenham outras vantagens em doentes e ambientes selecionados.
Todos os doentes devem receber tratamento para diminuição da tensão arterial e frequência cardíacas e controlo da dor. Se a dissecção for de tipo A, a cirurgia é emergente. Em caso de dissecção incompleta do arco, devem-se considerar as suas características e individualidade do doente antes de optar por reparação total ou do hemiarco. Doentes com défices neurológicos não devem ser submetidos a cirurgia, embora sejam necessários mais estudos para corroborar esta afirmação. Doentes com síndrome de má perfusão devem ser submetidos a cirurgia ou tratamento híbrido imediato. Na dissecção aórtica aguda tipo B não complicada, o tratamento é médico e de suporte. São necessários estudos randomizados sobre a eficácia do uso profilático de intervenção endovascular nestes doentes. Se complicada, deve optar-se por abordagem endovascular, com ou sem fenestração ou stenting adjuvantes, em doentes sem limitações anatómicas. Caso contrário, deve-se realizar cirurgia aberta. Apesar dos avanços no diagnóstico e tratamento da dissecção aórtica aguda, o sucesso permanece subótimo.
Acute aortic dissection is a life-threatening condition, with significant morbidity and a mortality rate of 1-2% per hour if left untreated, so it needs a quick diagnosis and early intervention. The aim of this work is to review the acute aortic dissection and state-of-the-art in its diagnosis and treatment. The information considered relevant was selected in the literature available and in scientific papers published in the last five years, in English, searched in "PubMed" search engine. The most common symptom is the sudden onset of an intense pain, described as a "feeling of tearing or stabbing." After the anamnesis, physical examination and routine laboratory tests, new biomarkers have emerged with potential diagnostic value. The most promising include D-dimers, extracellular matrix metalloproteinases, myosin heavy chain, soluble fragments of elastin, endothelin and beta transforming growth factor. Chest X-ray may indicate the condition and the electrocardiogram indicates possible acute complications. The imagiological gold-standard for the diagnosis of acute aortic dissection is multidetector computed tomography, although magnetic resonance and transthoracic and transesophageal ultrasound have other benefits in selected patients and environments. Every patient should receive treatment to lower blood pressure and heart rate and to control the pain. If the dissection is type A, the surgery is emergent. In the presence of an incomplete arch dissection, one should consider its characteristics and the individuality of the patient before opting for total or hemiarch repair. Patients with neurological deficits should not undergo surgery, although further studies are needed to corroborate this statement. Patients with poor perfusion syndrome should receive immediate surgical repair or hybrid treatment. In uncomplicated acute type B aortic dissection, treatment is medical and supportive. Randomized studies are needed on the efficacy of prophylactic use of endovascular intervention in these patients. If its complicated, an endovascular approach should be chosen, with or without adjuvant fenestration or stenting, in patients without anatomical limitations. Otherwise, it must be held open surgery. Despite advances in diagnosis and treatment of acute aortic dissection, success remains suboptimal.
Acute aortic dissection is a life-threatening condition, with significant morbidity and a mortality rate of 1-2% per hour if left untreated, so it needs a quick diagnosis and early intervention. The aim of this work is to review the acute aortic dissection and state-of-the-art in its diagnosis and treatment. The information considered relevant was selected in the literature available and in scientific papers published in the last five years, in English, searched in "PubMed" search engine. The most common symptom is the sudden onset of an intense pain, described as a "feeling of tearing or stabbing." After the anamnesis, physical examination and routine laboratory tests, new biomarkers have emerged with potential diagnostic value. The most promising include D-dimers, extracellular matrix metalloproteinases, myosin heavy chain, soluble fragments of elastin, endothelin and beta transforming growth factor. Chest X-ray may indicate the condition and the electrocardiogram indicates possible acute complications. The imagiological gold-standard for the diagnosis of acute aortic dissection is multidetector computed tomography, although magnetic resonance and transthoracic and transesophageal ultrasound have other benefits in selected patients and environments. Every patient should receive treatment to lower blood pressure and heart rate and to control the pain. If the dissection is type A, the surgery is emergent. In the presence of an incomplete arch dissection, one should consider its characteristics and the individuality of the patient before opting for total or hemiarch repair. Patients with neurological deficits should not undergo surgery, although further studies are needed to corroborate this statement. Patients with poor perfusion syndrome should receive immediate surgical repair or hybrid treatment. In uncomplicated acute type B aortic dissection, treatment is medical and supportive. Randomized studies are needed on the efficacy of prophylactic use of endovascular intervention in these patients. If its complicated, an endovascular approach should be chosen, with or without adjuvant fenestration or stenting, in patients without anatomical limitations. Otherwise, it must be held open surgery. Despite advances in diagnosis and treatment of acute aortic dissection, success remains suboptimal.
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Keywords
Aorta Diagnóstico Dissecção Aórtica Aguda Estado da Arte Tratamento