Acute aortic dissection – vascular emergency with numerous pitfalls

Acute aortic syndrome comprises acute aortic dissection, aortic intramural haematoma and penetrating atherosclerotic ulcers of the aortic wall. It ranks, after acute coronary syndrome, as one of the most frequent acute life-threatening differential diagnoses of chest pain. Chances of survival would probably be good in the large majority of cases, assuming optimal therapeutic management including rapid diagnostic evaluation followed by immediate and appropriate treatment is provided. However, actual mortality rate in these patients is still currently higher than 40%, despite medical and surgical progress. This unfavourable prognosis for the most frequent variant of acute aortic syndrome--aortic dissection--is due to the wide variability of clinical symptoms. These are often initially unspecific and frequently lead to delays in establishing the correct diagnosis, possibly first recognised at autopsy. Even after a timely, correct diagnosis, there is still a considerably high mortality rate following surgery, even with younger patients. Whenever acute aortic dissection is suspected a diagnostic imaging study should immediately be obtained. In addition to CT angiography, transesophageal echocardiography is recommended, due to its flexibility, as the diagnostically most useful tool in this context. Based on three case reports of acute aortic dissection this paper critically discusses the problems in making a correct and timely diagnosis and also provides an overview of the current state of knowledge in the areas of pathophysiology, epidemiology, clinical symptomatology as well as appropriate case-related management and prognosis of acute aortic dissection.