LA DISSEZIONE ACUTA DELL’ AORTA:

EPIDEMIOLOGIA E CLINICA

Eduardo Bossone e Rodolfo Citro (*)

U.O. Utic-Cardiologia Ospedale di Cava dei Tirreni

(*) ASL SA 3 Vallo della Lucania Dipartimento Cardiovascolare

U.O. Utic-Cardiologia Ospedale San Luca Vallo della Lucania

La Dissezione Aortica Acuta (DAA) e’ una rara ma catastrofica emergenza cardiovascolare con una elevata mortalità se non appropriatamente trattata.

Essa si verifica con una frequenza di almeno 2000 casi all’ anno negli USA. Ha una prevalenza di 0.5 – 2.95 /100000/anno con la più alta frequenza in Italia 4.04 /100000/anno. Sono tre i sistemi di classificazione utilizzati per la AAD: DeBakey: Tipo I-II-III, Stanford: Tipo A e B, Descrittivo: prossimale e distale. Esse riflettono la sede e l’ estensione del coinvolgimento aortico e si basano sullo stesso principio: distinguono le dissezioni aortiche con o senza l’ interessamento dell’ aorta

Classificazione della sindrome aortica acuta

Classificazione secondo Standford

Tipo A: dissezione dell’aorta ascendente con o senza l’ interessamento dell’ aorta discendente

Tipo B: dissezione soltanto dell’aorta discendente.

Classificazione secondo De Bakey

Tipo 1: dissezione dell’intera aorta

Tipo 2: dissezione aorta ascendente

Tipo 3: dissezione dell’aorta discendente

Nuova Classificazione ESC

Classe 1: classica dissezione aortica con presenza di flap tra vero e falso lume

Classe 2: distruzione della media con formazione di ematoma/emorragia intramurale

Classe 3: minima dissezione senza ematoma e con espansione eccentrica in corrispondenza della lesione

Classe 4: rottura di placca aterosclerotica con formazione di ulcerazione, ulcera penetrante con ematoma perilesionale, usualmente sottoavventiziale.

Classe 5: dissezione iatrogena e traumatica

Modified from: Erbel R, Alfonso F, Boileau C, et al. Diagnosis and management of aortic dissection: task force report of the European Society of Cardiology. Eur Heart J. 2001; 22: 1642–1681

In linea con altre patologie cardiovascolari (infarto del miocardio, stroke, ipertensione arteriosa) la DAA esibisce un ritmo circadiano e circannuale. Essa infatti è piu’ frequente di mattina e durante l’ inverno.

Per la non specificità dei sintomi e segni la diagnosi resta difficile. Quindi risulta indispensabile un elevato sospetto clinico seguito da un test di imaging: ecocardiografia transesofagea, tomografia assiale computerizzata, risonanza magnetica nucleare, aortografia. Esse hanno tutte un’alta sensibilità e specificità anche se la TAC è la più utilizzata seguita dalla TEE.

E’da sottolineare che nonostante i notevoli progressi in termini di tecniche diagnostiche e terapeutiche (mediche, endovascolari e chirurgiche), la mortalità della DAA resta comunque elevata.

Anche dopo un efficace “definitivo” trattamento della DAA, i pazienti rimangono ad un considerevole rischio di successive dissezioni, aneurismi e rotture dell’ aorta. Sono, quindi, necessari controlli clinici e diagnostici seriati.

Tab. I. Late complications of aortic valve dissection and follow-up evaluation.

1. Late complications

a. Progressive aortic insufficiency

b. Aneurysm formation and rupture

c. Recurrent dissection or progression of dissection

d. Leakages at anastomoses/stent sites

e. Malperfusion

2. Patients at particularly high risk

f. Those with Marfan syndrome-very high risk of recurrent dissection or of aneurysm formation with rupture

g. Those with a patent false lumen-increased incidence of late complications and death

3. Follow-up evaluation

h. Regular outpatients visits and imaging controls at 1, 3, 6 and 12 month and thereafter every year

i. Optimal BP control <135/80 mmHg with B –blockers

l. First choice is MRI, 2^nd choice CT and 3nd TEE.

Modified from: Erbel R, Alfonso F, Boileau C, et al. Diagnosis and management of aortic dissection: task force report of the European Society of Cardiology. Eur Heart J. 2001; 22: 1642–1681; Isselbacher EM. Aortic dissection in Atlas of Vascular Disease, Creager MA Second Edition (Series Editor Braunwald E); Current Medicine LLC, Philadelphia, PA, USA 2003, 24-43.

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