Aortic dissection resident survival guide: Difference between revisions
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{{familytree | | | | | | | | | | A01 |-| A02 |-| | {{familytree | | | | | | | | | | | | A01 |-| A02 |-| A03 | | | | |A01=<div style="float: left; text-align: left; padding:1em">'''Confirmed aortic dissection''' <br> ❑ Check whether dissection occurred in ascending aorta </div>|A02=Yes |A03=Consider surgical management}} | ||
{{familytree | | | | | | | | | | |! | {{familytree | | | | | | | | | | | | |!| | | | | | | | | | | | | |}} | ||
{{familytree | | | | | | | | | | | {{familytree | | | | | | | | | | | | B01 | | | | | | | | | | | | |B01=No}} | ||
{{familytree | | | | | | | | | | |! | {{familytree | | | | | | | | | | | | |!| | | | | | | | | | | | | |}} | ||
{{familytree | | | | | | | | | | | {{familytree | | | | | | | | | | | | C01 | | | | | | | | | | | | |C01=<div style="float: left; text-align: left; padding:1em">❑ Start Medical management </div>}} | ||
{{familytree | | | | | | | | | | | | {{familytree | | | | | | | | | | | | |!| | | | | | | | | | | | | |}} | ||
{{familytree | | | | | | | | | | | {{familytree | | | | | | | | | | | | D01 | | | | | | | | | | | | |D01=<div style="float: left; text-align: left; padding:1em">❑ Check Vitals <br> | ||
:❑ Blood pressure in both arms <br> | :❑ Blood pressure in both arms <br> | ||
:❑ Take the highest reading for treatment or goal therapy <br> | :❑ Take the highest reading for treatment or goal therapy <br> | ||
❑ Is patient hemodynamically stable ?</div> }} | ❑ Is patient hemodynamically stable ?</div> }} | ||
{{familytree | | | | | |,|-|-|-|- | {{familytree | | | | | | | | |,|-|-|-|^|-|-|-|-|-|-|-|.| | | | | |}} | ||
{{familytree | | | | | | {{familytree | | | | | | | | E01 | | | | | | | | | | E02 | | | | |E01=Yes |E02=No}} | ||
{{familytree | | | | | |!| | | | | | | | | | {{familytree | | | | | | | | |!| | | | | | | |,|-|-|-|^|-|-|-|.| |}} | ||
{{familytree | | | | | | {{familytree | | | | | | | | F01 | | | | | | F02 | | | | | | F03 |F01=<div style="float: left; text-align: left; padding:1em">❑ Control rate and pressure<br> | ||
: ❑ I.V [[Beta blockers]] or [[labetalol]] | : ❑ I.V [[Beta blockers]] or [[labetalol]] | ||
: ❑ Substitute [[diltiazem]] and [[verapamil]]<br> If [[betablockers]] are contraindicated | : ❑ Substitute [[diltiazem]] and [[verapamil]]<br> If [[betablockers]] are contraindicated | ||
Line 297: | Line 297: | ||
---- | ---- | ||
❑ Pain control<br> | ❑ Pain control<br> | ||
: ❑ Use [[Opiates]]</div> | | : ❑ Use [[Opiates]]</div> |F02=<div style="float: left; text-align: left; padding:1em"> ❑ '''Type A dissection''' | ||
---- | ---- | ||
❑ Expedited surgical consultation and consider surgery (Urgent)<br> | ❑ Expedited surgical consultation and consider surgery (Urgent)<br> | ||
Line 306: | Line 306: | ||
: ❑ [[Cardiac tamponade|Pericardial tamponade]] | : ❑ [[Cardiac tamponade|Pericardial tamponade]] | ||
: ❑ [[Aortic rupture|Rupture of aorta]]<br> | : ❑ [[Aortic rupture|Rupture of aorta]]<br> | ||
: ❑ [[Aortic insufficiency]]</div>| | : ❑ [[Aortic insufficiency]]</div>|F03=<div style="float: left; text-align: left; padding:1em">❑ Type B dissection | ||
---- | ---- | ||
❑ Intravenous fluid replacement<br> | ❑ Intravenous fluid replacement<br> | ||
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---- | ---- | ||
❑ Consider surgical evaluation</div> }} | ❑ Consider surgical evaluation</div> }} | ||
{{familytree | | | | | |! | {{familytree | | | | | | | | |!| | | | | | | |!| | | | | | | |!| |}} | ||
{{familytree | | | | {{familytree | | | | | | | | |!| | | | | | | G01 | | | | | | |!| |G01=<div style="float: left; text-align: left; padding:1em">❑ Can the cause of hypotension respond to surgical management</div>}} | ||
{{familytree | | | | {{familytree | | | | | | | | |!| | | |,|-|-|-|^|-|-|-|.| | | |!| |}} | ||
{{familytree | | | {{familytree | | | | | | | | H01 |-| H02 | | | | | | H03 |-| H04 |H01=<div style="float: left; text-align: left; padding:1em">❑ Monitor vitals closely | ||
: ❑ Maintain systolic BP <120 mm of | : ❑ Maintain systolic BP <120 mm of Hg</div> |H02=No |H03=Yes |H04=Consider surgical management}} | ||
{{familytree | {{familytree | | | | |,|-|-|-|^|-|-|-|.| | | | | | | | | | | | | |}} | ||
{{familytree | | | | I01 | | | | | | I02 | | | | | | | | | | | | |I01=Yes |I02=No}} | |||
{{familytree | | | {{familytree | | | | |!| | | | | | | |!| | | | | | | | | | | | | |}} | ||
{{familytree | | |!| | | | | | | |!| | | | | | | | | | {{familytree | | | | |!| | | | | | | J01 |-|-|-|-|-| J02 | | | | |J01=<div style="float: left; text-align: left; padding:1em"> ❑ Check whether dissection involves ascending aorta</div> |J02=Yes}} | ||
{{familytree | | | | {{familytree | | | | |!| | | | | | | |!| | | | | | | |!| | | | | |}} | ||
{{familytree | | | | {{familytree | | | | |!| | | | | | | K01 | | | | | | |!| | | | | |K01=No}} | ||
{{familytree | | | | {{familytree | | | | |!| | | | | | | |!| | | | | | | |!| | | | | |}} | ||
{{familytree | {{familytree | | | | |`|-|-| L01 |-|-|'| | | | | | | |!| | | | | |L01=<div style="float: left; text-align: left; padding:1em">❑ Control blood pressure | ||
: ❑ Intravenous vasodilator</div>}} | |||
{{familytree | | | {{familytree | | | | | | | | |!| | | | | | | | | | | |!| | | | | |}} | ||
: ❑ Intravenous vasodilator</div> | {{familytree | | | | | | | | M01 | | | | | | | | | | |!| | | | | |M01=<div style="float: left; text-align: left; padding:1em">❑ Monitor vitals closely | ||
{{familytree | | | | : ❑ Maintain systolic BP <120 mm of Hg</div>}} | ||
{{familytree | | | {{familytree | | | | | | | | |!| | | | | | | | | | | |!| | | | | |}} | ||
: ❑ Maintain systolic BP <120 mm of | {{familytree | | | | | | | | N01 |-| N02 |-| N03 |-|-|'| | | | | |N01=<div style="float: left; text-align: left; padding:1em">❑ Check for any complications which might require surgery | ||
{{familytree | | | | |||
{{familytree | | | |||
---- | ---- | ||
: ❑ Malperfusion | : ❑ Malperfusion | ||
: ❑ Progressing dissection | : ❑ Progressing dissection | ||
: ❑ Expansion of aortic aneurysm | : ❑ Expansion of aortic aneurysm | ||
: ❑ [[Hypertension causes|Uncontrolled or refractory hypertension]] </div> | | : ❑ [[Hypertension causes|Uncontrolled or refractory hypertension]] </div> |N02=Yes|N03=<div style="float: left; text-align: left; padding:1em">❑ Consider surgical management</div>}} | ||
{{familytree | | | | {{familytree | | | | | | | | |!| | | | | | | | | | | | | | | | | |}} | ||
{{familytree | | | {{familytree | | | | | | | | O01 | | | | | | | | | | | | | | | | |O01=No}} | ||
{{familytree | | | | {{familytree | | | | | | | | |!| | | | | | | | | | | | | | | | | |}} | ||
{{familytree | | | {{familytree | | | | | | | | P01 | | | | | | | | | | | | | | | | |P01=<div style="float: left; text-align: left; padding:1em">❑ Switch to oral medications <br> | ||
:❑ [[Betablockers]] | :❑ [[Betablockers]] | ||
:❑ Antihypertensive regimen | :❑ Antihypertensive regimen | ||
---- | ---- | ||
❑ Follow up in the outpatient</div> | ❑ Follow up in the outpatient</div>}} | ||
{{familytree/end}} | {{familytree/end}} | ||
Shown below is an algorithm depicting the surgical management of [[Aortic dissection]] according to the Guidelines for Diagnosis and Management of patients with Thoracic Aortic Disease.<ref name="circ.ahajournals.org">{{Cite web | last = | first = | title = http://circ.ahajournals.org/content/121/13/e266.full | url = http://circ.ahajournals.org/content/121/13/e266.full | publisher = | date = | accessdate = }}</ref> | Shown below is an algorithm depicting the surgical management of [[Aortic dissection]] according to the Guidelines for Diagnosis and Management of patients with Thoracic Aortic Disease.<ref name="circ.ahajournals.org">{{Cite web | last = | first = | title = http://circ.ahajournals.org/content/121/13/e266.full | url = http://circ.ahajournals.org/content/121/13/e266.full | publisher = | date = | accessdate = }}</ref> | ||
Revision as of 22:28, 1 April 2014
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Chetan Lokhande, M.B.B.S [2]
Aortic dissection resident survival guide Microchapters |
---|
Overview |
Classification |
Causes |
Diagnosis |
Treatment |
Do's |
Dont's |
Overview
Aortic dissection is a tear in the layers of the aorta especially in the intima leading to bleeding and separation of the layers of the aorta from within which creates a false lumen. Aortic dissection is a medical emergency and can quickly lead to death, even with optimal treatment, as a result of decreased blood supply to other organs, cardiac failure, and sometimes rupture of the aorta. Diagnosis is made with imaging studies like Transesophageal echocardiography (TEE), Computed tomography (CT) or Magnetic resonance imaging (MRI). Treatment depends according to the anatomic location of the aorta involved. Surgery is usually required for dissections that involve the aortic arch, while dissections of the part further away from the heart may be treated with antihypertensive medications.
Aortic dissection can be further classifies as:
- Acute aortic dissection- Dissection occurring within 2 weeks of onset of pain
- Subacute aortic dissection-Dissection occurring witin 2-6 weeks of onset of pain
- Chronic aortic dissection- Dissection occurring within 6 weeks of pain.
Classification
Aortic dissection can be classified into four types. DeBakey and Daily (Stanford) systems are the commonly used systems used to classify aortic dissection.[1][2][3][4]
- Stanford system classifies dissection into the following two types based on whether ascending aorta is involved or not.
- Ascending aortic dissection or type A
- All other dissections or type B
- DeBakey system classifies dissection according to location of the tear.
- Type I- Starts at ascending aorta and extends upto the aortic arch
- Type II- Starts and is limited till the ascending aorta
- Type III- Starts in the descending aorta and progresses proximally or distally
- Type III A - Restricted till the descending thoracic aorta
- Type III B - Dissection extending below the diaphragm
- The third type of classification divides aortic dissection according to the proximity
- Proximal- Ascending aortic involvement
- Distal- Descending aortic involvement distal to left subclavian artery
Causes
Life Threatening Causes
Aortic dissection is a life-threatening condition and must be treated as such irrespective of the causes. Life-threatening conditions may result in death or permanent disability within 24 hours if left untreated.
Common Causes
- Atherosclerosis
- Complication of cardiac procedures
- Chest trauma
- Connective tissue disorders
- Hypertension
- Vasculitis[5]
First Initial Rapid Evaluation of Suspected Aortic Dissection
Shown below is an algorithm for the First Initial Rapid Evaluation (FIRE) of Aortic dissection.
❑ Identify cardinal signs and symptoms that increase the pretest probability of acute aortic rupture | |||||||||||||||||||||||||||||||||||||||||||||
❑ Sudden onset chest pain (tearing/ripping/sharp or stabbing) ❑ Asymmetric blood pressure in extremities | |||||||||||||||||||||||||||||||||||||||||||||
Unstable patient | Stable patient | ||||||||||||||||||||||||||||||||||||||||||||
❑ Order urgent TTE ❑ Look for the following high risk features:
| Continue with diagnostic approach | ||||||||||||||||||||||||||||||||||||||||||||
❑ Aortic dissection confirmed
❑ Transfer to Cardio-thoracic unit | |||||||||||||||||||||||||||||||||||||||||||||
❑ Proceed to surgery | |||||||||||||||||||||||||||||||||||||||||||||
Diagnosis
Shown below is a diagnostic algorithm depicting the management of Aortic dissection according to the 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for Diagnosis and Management of patients with Thoracic Aortic Disease.[6]
Characterize the symptoms: ❑ Cardiac
❑ Extra cardiac
| |||||||||||||||||||||||||||||||||||||||||||||||||||
Obtain a detailed history: ❑ Family history
❑ Anatomic deformities
❑ Iatrogenic
❑ Lifestyle
❑ Trauma
❑ Inflammatory vasculitis ❑ Aortitis | |||||||||||||||||||||||||||||||||||||||||||||||||||
Examine the patient: ❑ General examination:
❑ Head/neck examination:
❑ Cardiovascular examination:
❑ Respiratory examination
❑ Abdominal examination:
❑ Neurological examination:
❑ Extremity examination: ❑ Ophthalmological examination | |||||||||||||||||||||||||||||||||||||||||||||||||||
❑ Assess the severity by counting the high risk features marked in bold and by * | |||||||||||||||||||||||||||||||||||||||||||||||||||
Consider alternate diagnosis:
| |||||||||||||||||||||||||||||||||||||||||||||||||||
Low Risk ❑ No high risk features present ❑ Clinical presentation is not initially suggestive for dissection but aortic imaging may help in the absence of alternative diagnosis | Intermediate Risk ❑ Single high risk present ❑ Concerning presentation for acute dissection and requires aortic imaging if no alternate diagnosis can be reached | High Risk ❑ Two or more high risk features present ❑ Acute dissection requiring immediate surgical evaluation and expedited aortic imaging | |||||||||||||||||||||||||||||||||||||||||||||||||
❑ Can alternate diagnosis be ruled out | ❑ Order an EKG
❑ Does EKG show ST elevation | ||||||||||||||||||||||||||||||||||||||||||||||||||
Yes | No | Yes | No | ❑ Consider immediate surgical consultation and accelerate aortic imaging | |||||||||||||||||||||||||||||||||||||||||||||||
❑ Treat accordingly | ❑ Initiate appropriate therapy
❑ Check whether it helped to alleviate the symptom
| ❑ Order a coronary angiography and Treat like a primary acute coronary syndrome (ACS) unless perfusion deficits are present then consider immediate coronary reperfusion therapy ❑ Can the lesion be identified by coronary angiography | |||||||||||||||||||||||||||||||||||||||||||||||||
No | Yes | Yes | No | ||||||||||||||||||||||||||||||||||||||||||||||||
❑ Evaluate clinical scenario for risk factors for Thoracic Aortic Disease (TAD)
| Detailed and accelerated aortic imaging | ||||||||||||||||||||||||||||||||||||||||||||||||||
❑ Do a detailed aortic imaging for thoracic aortic disease | ❑ Accelerated aortic Imaging
{{#ev:youtube|14mKjEOLNWM}}
| ||||||||||||||||||||||||||||||||||||||||||||||||||
❑ Can aortic dissection be confirmed by imaging study | |||||||||||||||||||||||||||||||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||||||||||||||||||||||||||||||
❑ Start appropriate therapy | ❑ Obtain a secondary imaging study if there is high cinical suscpicion even if the initial aortic imaging studies are negative | ||||||||||||||||||||||||||||||||||||||||||||||||||
Treatment
Shown below is an algorithm depicting the medical management of Aortic dissection according to the Guidelines for Diagnosis and Management of patients with Thoracic Aortic Disease.[6]
Confirmed aortic dissection ❑ Check whether dissection occurred in ascending aorta | Yes | Consider surgical management | |||||||||||||||||||||||||||||||||||||||||||||||||||
No | |||||||||||||||||||||||||||||||||||||||||||||||||||||
❑ Start Medical management | |||||||||||||||||||||||||||||||||||||||||||||||||||||
❑ Check Vitals
| |||||||||||||||||||||||||||||||||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||||||||||||||||||||||||||||||||
❑ Control rate and pressure
❑ Goal Heart rate should be 60 beats per minute ❑ Pain control
| ❑ Type A dissection
❑ Expedited surgical consultation and consider surgery (Urgent)
❑ Rule out complications using imaging study | ❑ Type B dissection
❑ Intravenous fluid replacement
❑ Start vasopressor if still hypotensive ❑ Find out etiology of hypertension
❑ Consider surgical evaluation | |||||||||||||||||||||||||||||||||||||||||||||||||||
❑ Can the cause of hypotension respond to surgical management | |||||||||||||||||||||||||||||||||||||||||||||||||||||
❑ Monitor vitals closely
| No | Yes | Consider surgical management | ||||||||||||||||||||||||||||||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||||||||||||||||||||||||||||||||
❑ Check whether dissection involves ascending aorta | Yes | ||||||||||||||||||||||||||||||||||||||||||||||||||||
No | |||||||||||||||||||||||||||||||||||||||||||||||||||||
❑ Control blood pressure
| |||||||||||||||||||||||||||||||||||||||||||||||||||||
❑ Monitor vitals closely
| |||||||||||||||||||||||||||||||||||||||||||||||||||||
❑ Check for any complications which might require surgery
| Yes | ❑ Consider surgical management | |||||||||||||||||||||||||||||||||||||||||||||||||||
No | |||||||||||||||||||||||||||||||||||||||||||||||||||||
❑ Switch to oral medications
❑ Follow up in the outpatient | |||||||||||||||||||||||||||||||||||||||||||||||||||||
Shown below is an algorithm depicting the surgical management of Aortic dissection according to the Guidelines for Diagnosis and Management of patients with Thoracic Aortic Disease.[6]
❑ Imaging study confirms aortic dissection ❑ Check whether dissection occurred in ascending aorta | No | ||||||||||||||||||||||||||||||||||||||||||||
Yes | |||||||||||||||||||||||||||||||||||||||||||||
❑ Assess suitability for surgery ❑ Patient stable for pre-op testing? | No | Medical management | |||||||||||||||||||||||||||||||||||||||||||
Yes | |||||||||||||||||||||||||||||||||||||||||||||
❑ Age > 40? | No | ||||||||||||||||||||||||||||||||||||||||||||
Yes | |||||||||||||||||||||||||||||||||||||||||||||
❑ Assess need for pre-operative coronary angiography
| No | ||||||||||||||||||||||||||||||||||||||||||||
Yes | |||||||||||||||||||||||||||||||||||||||||||||
❑ Perform angiography Is significant CAD detected on angiography? | No | ||||||||||||||||||||||||||||||||||||||||||||
Yes | |||||||||||||||||||||||||||||||||||||||||||||
❑ Plan for CABG at the time of aortic dissection repair | |||||||||||||||||||||||||||||||||||||||||||||
❑ Perform urgent operative management | |||||||||||||||||||||||||||||||||||||||||||||
❑ Perform intra-operative assessment of aortic valve by Transesophageal echocardiography (TEE) for presence of one of the following:
| |||||||||||||||||||||||||||||||||||||||||||||
No | Yes | ||||||||||||||||||||||||||||||||||||||||||||
❑ Perform graft replacement of ascending aorta ± aortic arch | ❑ Perform graft replacement of ascending aorta ± aortic arch ❑ Consider repair/replacement of aortic valve | ||||||||||||||||||||||||||||||||||||||||||||
Do's
History and Examination
- For pre-test risk determination include information about:
- Medical History
- Family history and ask specifically for family history of aortic dissection or thoracic aneurysm
- Pain history
- Do a detailed physical examination to identify findings for certain high risk conditions like: (class I, level of evidence B)
- Marfan's syndrome
- Loeys-Dietz syndrome
- Ehlers-Danlos syndrome
- Turner's syndrome
- Connective tissue disorder
- Check for genetic mutations predisposing to dissection: (class I, level of evidence B)
- Any recent aortic or surgical or catheter manipulation. (class I, level of evidence C)
- Ask in detail about the pain. Include the following: (class I, level of evidence B)
- Onset of pain whether abrupt or instantaneous
- Severity of pain
- Quality of pain whether ripping, tearing,stabbing or sharp.
- Check for the following features on examination: (class I, level of evidence B)
- Pulse deficits
- Blood pressure (systolic) difference of above 20 mm of hg in limbs
- New aortic regurgitation features
- Focal neurological deficit
- Patients less than 40 years of age and presenting with sudden chest, abdominal or back pain should be evaluated for high risk conditions.
- Patients presenting with features of syncope along with features of dissection should have a detailed neurological examination and cardiovascular examination to rule out pericardial tamponade and other neurological deficits. (class I, level of evidence C)
Screening Tests
- Do an EKG on all patients with dissection symptoms. (class I, level of evidence B)
- If ST elevation is present in EKG then treat the patient as an acute cardiac event unless the patient has high risk factors for acute dissection.
- If EKG shows ST elevation with no dissection features then perform a coronary angiography and then do a thrombolysis or percutaneous coronary intervention.
- Do a X-ray for all patients with intermediate risk and low risk to rule out alternate diagnosis. (class I, level of evidence C)
- High risk patients should be evaluated by transesophageal echocardiogram, computed tomography or magnetic resonance imaging to rule out dissection. (class I, level of evidence B)
- Obtain a secondary imaging study if there is high cinical suscpicion even if the initial aortic imaging studies are negative. class III, level of evidence C
Initial Management
- Medical management should be aimed at decreasing aortic wall stress. (class I, level of evidence C)
- Titrate Beta blocker to maintain heart rate of 60 beats/ minute. (class I, level of evidence C)
- If beta blockers are contra indicated then use nondihyropyridine calcium channel blockers to control rate. (class I, level of evidence C)
- If BP remains above 120 mm of hg even after medical treatment then use angiotensin converting enzyme and other vasodilators to maintain end organ perfusion. (class I, level of evidence C)
Definitive Management
- Do a surgical consultation for all patients once diagnosed with aortic dissection. This applies to patients presenting with dissection at any location. (class I, level of evidence C)
- Do an emergent repair in acute dissection of ascending aorta to prevent complications like rupture. (class I, level of evidence C)
- Treat all descending aorta medically unless complicated by life threatening conditions like perfusion deficit, dissection enlargement, aneurysmal enlargement or blood pressure refractory to treatment. (class I, level of evidence C)
- Do a definitive aortic imaging study as soon as Chest X-ray suggests widened mediastinum.
- Goal should be to maintain heart rate less than 60 beats / minute and blood pressure between 100 and 120 mm hg.
- Use Esmolol if asthma, congestive heart failure or chronic obstructive pulmonary disease.
- Use Labetalol to maintain heart rate and blood pressure, it prevents usage of another vasodilator.
- Do pericardiocentes for pericardial bleeding and dissection related hemopericardium.
- Do a plasma smooth muscle myosin heavy chain protein, D-dimer and high sensitive C-reactive protein to rule out alternate diagnosis.
Dont's
- Don't use beta blocker in patients having aortic regurgitation as they may block the tachycardia caused by compensation.
- Don't use vasodilator before heart rate is controlled otherwise there would be reflex tachycardia which would increase the stress on aorta and worsening the dissection.
- Use Sodium nitroprusside as the first line for treating hypertension. Nicardipine, nitroglycerin and fenoldopam are other drugs used to treat hypertension.
- Don't delay aortic imaging even if chest x-ray is negative. (class III, level of evidence C).
References
- ↑ Nienaber, CA.; Eagle, KA. (2003). "Aortic dissection: new frontiers in diagnosis and management: Part I: from etiology to diagnostic strategies". Circulation. 108 (5): 628–35. doi:10.1161/01.CIR.0000087009.16755.E4. PMID 12900496. Unknown parameter
|month=
ignored (help) - ↑ Tsai, TT.; Nienaber, CA.; Eagle, KA. (2005). "Acute aortic syndromes". Circulation. 112 (24): 3802–13. doi:10.1161/CIRCULATIONAHA.105.534198. PMID 16344407. Unknown parameter
|month=
ignored (help) - ↑ DEBAKEY, ME.; HENLY, WS.; COOLEY, DA.; MORRIS, GC.; CRAWFORD, ES.; BEALL, AC. (1965). "SURGICAL MANAGEMENT OF DISSECTING ANEURYSMS OF THE AORTA". J Thorac Cardiovasc Surg. 49: 130–49. PMID 14261867. Unknown parameter
|month=
ignored (help) - ↑ Daily, PO.; Trueblood, HW.; Stinson, EB.; Wuerflein, RD.; Shumway, NE. (1970). "Management of acute aortic dissections". Ann Thorac Surg. 10 (3): 237–47. PMID 5458238. Unknown parameter
|month=
ignored (help) - ↑ "Classification of diabetic retinopathy from fluorescein angiograms. ETDRS report number 11. Early Treatment Diabetic Retinopathy Study Research Group". Ophthalmology. 98 (5 Suppl): 807–22. 1991. PMID 2062514.
- ↑ 6.0 6.1 6.2 "http://circ.ahajournals.org/content/121/13/e266.full". External link in
|title=
(help)