Asked by Satish Desai, Dacula , Georgia
If someone with a type B aortic dissection needs to travel a long distance, for example from the United States to Asia, what precautions should be followed?
Dr. Otis Brawley
Chief Medical Officer,
American Cancer Society
Aortic dissection is a very serious illness. It is a tear in the aorta, the large blood vessel carrying oxygenated blood from the heart to the rest of the body. The aorta is really hoselike. It comes out of the top of the heart traveling upward a short distance, with the carotid arteries to the brain branching off, and then it curves downward. Smaller blood vessels that supply the arms and the rest of the body with blood stem off the aorta. When the aorta gets to the pelvis, it divides into the two femoral arteries, which supply the legs.
The tear can be incomplete and not through the full thickness of the aorta. It can also be a complete tear, meaning a hole is created, causing internal bleeding. Many patients die immediately from the initial tear and resultant internal bleeding before they even get medical attention.
Those who survive the initial tear typically have sudden onset of severe, sharp or "tearing" chest or back pain. The patient may also have a weak or absent carotid, brachial, or femoral pulse as blood flow to these areas is decreased. The diagnosis of aortic dissection is generally made by an astute physician noninvasively by ultrasound of the chest (echocardiogram), computed tomography scan (CT), or thoracic magnetic resonance imaging (MRI). It can be easily mistaken for a heart attack or even esophageal spasm.
Risk factors for a dissection include older age, a history of cardiovascular or peripheral vascular disease, a history of hypertension, and smoking. People who have an aortic aneurysm or a weakening and out-pouching of the aorta are at especially high risk of dissection. Risk factors for aortic aneurysms include those mentioned for dissection as well as genetic diseases such as Marfan syndrome or connective tissue disorders such as Ehlers-Danlos syndrome.
The Stanford system is the most common of several systems for classifying dissections. Dissections that involve the ascending aorta, the part immediately leaving the heart, are called type A; type B dissections involve the aorta after it is descending.
Acute type A dissection is a surgical emergency. The preferred surgery involves a cardiovascular surgeon opening the chest and placing a synthetic patch over the dissection of the aorta to strengthen it. This surgery is extremely dangerous and is often not successful. Patients who survive the surgery are at high risk for having serious damage to organs that were deprived of oxygen. The kidneys and small bowel are especially vulnerable.
Most type B dissections are actually treated medically unless the patient demonstrates continued bleeding into the chest or the retroperitoneal space (the space behind the abdomen). Medical therapy consists of oral medications to slow the heart rate and reduce blood pressure. A combination of several antihypertensive drugs is usually required. This minimizes stress on the aortic wall. Avoiding strenuous physical activity is also recommended as another method to minimize aortic shear stress. The patient should be regularly screened for evidence of the dissection increasing in size.
Stent grafting is sometimes done as a minimally invasive surgical treatment in selected type A and B dissections that are stable but at high risk for the tear extending or opening to cause internal bleeding. In this procedure, catheters are placed into the femoral artery of the groin and the graft is moved up to the level of the tear and put into place. X-rays are used to identify and assure the appropriate location of the graft. The best candidates for grafts are those who have undergone medical therapy for several months and are stable. Stent grafting is not as effective for type A dissections nor for any acute active life-threatening dissections.
In direct answer to your question about travel, there is nothing about a long airplane ride that would put additional stress on the aorta and increase risk of worsening the dissection, as long as the patient does not do heavy lifting. I actually worry more about deep vein thrombosis (blood clots in the legs) from prolonged sitting.
I still recommend any patient with an illness who is contemplating travel have a good conversation about it with his or her physician. One question to consider is, if you do need complicated surgery while traveling, does the area you are traveling to have the ability to provide that care?
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