Search for tag: "arterial"

Interviewer: You have a loved one and you've been told they have an aortic dissection. What does that mean for them in the short term, and more importantly, the long term? That's next on The Scope.

Dr. Jason Glotzbach is a cardiothoracic surgeon at University of Utah Health and if somebody's been diagnosed with an aortic dissection, let's kind of break that down a little bit and help them understand what that means. Generally, it's probably not going to be that person that had it that will be finding out this information because it's a serious thing.

Dr. Glotzbach: Absolutely. So the aorta, as we've talked about, is the largest blood vessel in the body and the aorta has several layers to the aortic wall. It's kind of like plywood where the layers should be stuck together without any space in between them and sometimes due to high blood pressure or other things, you can get a small tear in the inside of the aorta, which then allows blood to travel in between the layers of the aortic wall.

We call it dissection because it dissects into the aorta and then once that blood gets in between the layers of the wall and separates them, that can cause major problems with the aorta.

Interviewer: So when it's in between those layers is it going to break out eventually and you'll be internally bleeding or what happens at that point?

Dr. Glotzbach: It can proceed to that, although more that's rare. More commonly, the blood dissection inside the wall of the aorta will travel kind of along the length of the aorta and it can block off the branches coming off the aorta. So it can prevent blood flow from going to all the branches of the aorta which can affect any area of the body because of those arteriole branches.

Interviewer: Including the brain?

Dr. Glotzbach: Absolutely, so it can involve the carotid arteries. Obviously if the carotid artery blood flow is decreased or impaired and then it can cause a stroke. Similarly, the blood vessels going to the liver or the spleen or the kidneys or the intestines, if those are blocked off then you can have major problems in the abdomen. So it really is a critically dangerous problem once it develops.

Interviewer: And I understand that there are two different types of aortic dissections that somebody might be diagnosed with. For the understanding of, you know, a loved one that might have another loved one that's dealing with this, could you explain briefly what those two are?

Dr. Glotzbach: Absolutely, and we break it down anatomically by kind of location within the aorta and so the two types are type A and type B.

Type A aortic dissection involves the first part of the aorta coming right off the heart, so also known as the ascending aorta. And a type A dissection is a surgical emergency. Those patients need to go as quickly as possible to the operating room with a cardiovascular surgeon to repair that.

Type B aortic dissection involves the rest of the aorta, so from the aortic arch on down and including the abdomen. And so type B dissections are a little bit more complicated or nuanced in that they may require surgery or a procedure. They might not, but they definitely would need to be in the hospital.

So those two distinctions are critical for the initial treatment phase, although all aortic dissections really should be thought of as a chronic disease and so once this happens to the aorta, patients will need lifelong surveillance with imaging studies and follow up with an aortic specialist to make sure that problems don't develop down the road.

Interviewer: And what caused that to happen? Is it something that the patient did or did it just happen?

Dr. Glotzbach: It can be both. There are risk factors including smoking and high blood pressure. There are some genetic conditions or familial patterns that can predispose people to have this problem. One of the biggest risk factors for aortic dissection is developing an aortic aneurysm, which is an enlarged area of the aorta which gets thinned out and weakens, so that's more susceptible to a dissection. But a lot of times these are just bad luck and this happens to someone who's never had an aortic problem before and this just kind of happens out of the blue, so it can be a devastating problem.

Interviewer: Are there any sort of warning symptoms that would come before the actual emergency event?

Dr. Glotzbach: Unfortunately, there are not a lot of warning symptoms. A lot of, you know, an aortic aneurysm is largely asymptomatic. High blood pressure can cause a bit of a warning, and then obviously people that have known aortic problems. But most people who have a dissection have no warning sign or nothing that suggests this is about to happen until it actually does happen.

Interviewer: All right and once . . . How is it diagnosed?

Dr. Glotzbach: Typically it's severe pain and so patients who have a dissection have severe chest pain or back pain or abdominal pain or all three, and a lot of times it could mimic a heart attack or other kind of acute problems. So most people know something is going wrong and they have severe pain, which then usually people come to the emergency department with the symptoms and then it's diagnosed from there with an imaging study.

Interviewer: And how do they get fixed in the short term and then what's their long term look like?

Dr. Glotzbach: Absolutely. So for a type A dissection like we talked about, that's a surgical emergency so those patients go to the operating room and we will replace the ascending aorta at least and sometimes more. Sometimes the aortic valve can be involved or the coronary arteries need to be reconstructed. Basically need to stabilize that first part of the aorta so that the blood flow to the brain and to the rest of the aorta is preserved. So that's a type A.

For a type B, which is involving the rest of the aorta, the most critical thing is to keep the patient's blood pressure under control and then to determine if there is any problem with blood flow to any of the other organs. So we look at blood flow to the liver, the gut and the legs, the kidneys, all those things. As long as there's blood flow to those organs, typically we can manage those patients medically.

Interviewer: And what does life look like after somebody has an aortic dissection? Likely I'm talking, you know . . .

Dr. Glotzbach: Long term.

Interviewer: Three to five years.

Dr. Glotzbach: Absolutely. So once we've stabilized after the initial event, then it becomes kind of a chronic disease that needs to be managed and watched closely like any chronic disease. And so the way we do that for aorta, number one, is blood pressure control so we have to . . . most patients are on one or multiple blood pressure medications and then we do long term follow up with imaging studies. And typically that's a CAT scan or a CT scan, which is a three-dimensional X-ray that gives us a very good picture of the aorta and tells us exactly what's going on.

And so we'll have the initial imaging from when it first happened and then we'll get every, between six months to a year or so and every year after that we'll get CT scans watching how that aorta is changing or not and if things start to change then sometimes we need to do procedures in the future and sometimes not, sometimes people just remain stable and we just keep watching them.

Interviewer: So what I'm getting is that it's something that could happen again to somebody who's had one.

Dr. Glotzbach: It could, and once you've had an aortic dissection your aorta's at risk for life and so this is something that is, you know, can be managed and stable and people can go on living with it but it's not something that will ever heal completely and so people just have to be aware that they need lifelong surveillance and I think that's where a true aortic program comes in where you have a dedicated team of physicians and nurses and radiologists and people that are used to watching these over long term so that we can pick up on problems as they begin to develop, before they turn into big problems, we can intervene.

Interviewer: And what about quality of life?

Dr. Glotzbach: I think that this is a very serious emergency. When these happen, they're life threatening and should be taken seriously and treated immediately at a hospital and so the quality of life after that, once you've stabilized and treated from the initial event, people can go on living normal lives and do almost anything that they want to do provided they have good follow up care and we keep an eye on things and make sure that that aorta remains stable and doesn't develop complications down the road.

updated: August 25, 2021
originally published: August 23, 2017

Interviewer: This is one of those Scope podcasts we hope you never have to use, but it's good information to have in case you find yourself in this situation. How do you stop severe bleeding? We'll talk about that next on the Scope.

Announcer: This is From the Frontlines, with emergency room physician Dr. Troy Madsen on The Scope.

Interviewer: Dr. Troy Madsen is an emergency room physician at University Utah Healthcare. It's something you'll never have to do, but it could potentially save somebody's life, and buy medical experts the time they need if you have somebody who's bleeding severely, if you're able to slow that down. I'm in a situation where somebody is severely bleeding, what do I do?

Dr. Madsen: Well the number one thing to remember with severe bleeding is hold pressure. No matter what kind of bleeding it is. If it's oozing out, if it's spurting out, hold pressure on it, and just keep holding pressure. The biggest mistake I see with people is, let's say someone has, let's say a laceration on their arm from a knife or something they were working with.

People will want to keep looking at it. They'll say, "Wow, has it stopped?" They'll hold some pressure on there, or they'll put a bandage on it, and then they'll pull it off, 30 seconds to a minute later, they say, "Oh no, it's still bleeding." So they'll put it back on, and they'll say, "Oh no, it's still bleeding." They just keep looking at it.

The key is hold pressure on it, and just keep holding pressure. Don't keep pulling the bandage off to look at it. My recommendation is, if you're going to look at it, wait 15 minutes. Hold pressure on there, hold nice firm pressure. Make sure the pressure is firm, but also make sure it's also not cutting off circulation to their hand or their foot, or whatever might be below that laceration or that bleeding.

You want to make sure they can still move their fingers. Make sure their fingers still look pink. If you push on their fingernails it doesn't just turn white, and stay white, it turns pink again within about two or three seconds. So bottom line is, whatever it is, just hold pressure, and keep holding pressure.

Interviewer: All right, and then call somebody immediately.

Dr. Madsen: Yes. Call somebody immediately. Get in for medical attention, especially if we're talking about an arterial bleed. So the arteries are the vessels in the body that take the blood from the heart, so there you're seeing that pulsatile type bleeding where it's shooting out. That's definitely a more serious thing, and a person could lose blood very, very quickly with that. So that's something you want to call 911, get to a hospital quickly, so that can be addressed.

Interviewer: All right. But still, same thing, get like a cloth, a clean cloth, whatever, and hold pressure.

Dr. Madsen: Yes, exactly. One mistake sometimes you'll see too, maybe in a first aide class or scouts, Boy Scouts or something you learned about tourniquets. So you think to yourself, "Okay, this is an arterial bleed. I'm seeing this pulsatile bleeding shooting out, I'd better throw a tourniquet on this." The only time to use a tourniquet is when you expect that this person is going to lose whatever is below that tourniquet, whether it's their leg, it's their arm.

The only case I'd use a tourniquet, and the case I've used it, and I've seen it used would be someone who's been in say, some sort of motorcycle accident, something like that, and they've lost their lower leg. Basically, you're just trying to save their life. Their leg is pretty much lost, it's mangled, or it's pretty much gone. So you're just trying to control the bleeding into that area, and just assuming that everything below that tourniquet is gone.

Interviewer: Okay.

Dr. Madsen: So if you're going to put a tourniquet on, I would not recommend doing it. But the only scenario where you would do that would be where you just assume you're going to lose everything below that.

Interviewer: If I'm putting pressure on something like that, is their blood going to be getting out and around it? I mean, am I'm completely stopping the blood from escaping in most cases or not?

Dr. Madsen: With just putting pressure, or with a tourniquet?

Interviewer: Yeah. With putting pressure, what's that look like?

Dr. Madsen: So when you're putting pressure on something, you're just holding pressure directly over the wound, and you should have enough other arteries and veins, and everything running through there, you're still going to have blood flow to whatever is beyond that.

Interviewer: So it will bypass, it won't just continue to push past the pressure?

Dr. Madsen: Yeah. Exactly. Yeah, it's not like you just have one artery running down there that's then going to be blocked off, and everything's going to pool above it, or try to push back because so much pressure will build up where you're holding pressure.

Interviewer: It just reroutes.

Dr. Madsen: It will reroute, exactly. It's like a traffic jam where then everything goes on separate streets. Kind of same idea, but again, the key is just hold pressure, and avoid using some kind of tourniquet, or avoid tying something around the arm or leg that's going to cut off all the circulation down below there.

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