Another aortic dissection!

One day in Apr 2015, after she suddenly had enormous pain and breathing difficulties, she was again rushed to the same cardiac hospital.

A day after the admission, the chief doctor called me and in a harsh voice told me that we were recklessly playing with amma’s life.

Apparently, she had not been taking her blood pressure medicines properly, 49 at least that was the doctor’s best guess because actual records of what medicines she was taking were a bit patchy. Her blood pressure had again shot up dramatically.

I started protesting that she was actually taking all the prescribed medications, but stopped when I realized I really did not know how accurately she had been taking them.

Because of her high blood pressure – she had 200/110 when I rushed her to the hospital – there had been another aortic dissection. This time, the dissection started from where the first one had ended and extended all the way until her abdomen and even a bit beyond. 50

Fig 16: Recurrent aortic dissection: Amma’s recurrent dissection started from the proximal arch of the aorta, the place where the original dissection was and had been repaired by a graft, and went all the way until the end of the aorta which is at the abdomen. The dissection then proceeded into the iliac arteries that supply blood to the legs.

I sank in my chair. I could not imagine amma going through, and surviving, another painful surgery.

But the doctors were thinking differently. The medical team at the hospital had a meeting on this and however decided that the best course of action would not be a surgery, all things considered.

Instead, her dissection would be managed conservatively through a proper balance of medications. This line of treatment meant that if she kept her blood pressure under control all the time, the dissection would just stay put the way it was and not leak or rupture. 51

The doctors said that she could survive for many years without a leak from the dissection.

At that time, I understood little about the technicalities of what the doctors said, but could only ask them why they were not trying to do a surgery that stitched up the dissection, the way they had done it for her earlier dissection on the ascending aorta.

Given the extensive nature of the dissection this time round, the medical team felt surgery carried a very high risk for amma compared to a management by medications alone. Their recommendation for conservative management was also bolstered by the fact that the dissection this time was away from the heart. Farther the distance of a dissection from the heart, fewer are the risks of short term rupture. Thus, the ascending aortic dissection amma had in 2011 had a very high risk of short term rupture compared to this dissection whose starting point was a bit away from the heart.

The takeaway for me was that amma could live for many years with her torn and tattered aorta if she ensured that her blood pressure was always kept low.

Fig 17: Amma’s recurrent aortic dissection from various angles. The sections that are purple in color represent the dissected portions where the blood was flowing through the middle layer, known as the false lumen as it was not the intended channel (the true lumen) for the blood flow.

 All’s well. Really? <= Another aortic dissection! => She wouldn’t survive 10 hours!

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Notes

49. Strict control of hypertension with β‐blocker therapy for life is compulsory following repair of acute type A dissection.

50. It had started from the aortic arch and the dissection had gone all the way down until the end of the aorta – which was at the abdomen – and extended further into the iliac arteries that supply blood to the pelvic organs and legs.

51.  It’s a bit more nuanced, though. For the descending aorta, a conservative management through medicines is appropriate for an uncomplicated, stable dissection. However, should the dissection present complications such as extension of the dissection in the short term, loss of blood supply to some parts, rapidly growing aortic diameter etc., repair of the aorta will be required. Amma’s descending dissection was an uncomplicated one.

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