What is the treatment for aortic dissection (AoD) repair?

From the Guidelines

Aortic dissection repair should be performed surgically for Type A dissections, as it significantly reduces mortality and improves long-term outcomes, as evidenced by the most recent guidelines 1. The primary treatment approach for aortic dissection repair depends on the location of the dissection.

Key Considerations

• For Type A dissections (involving the ascending aorta), emergency open-heart surgery is the recommended treatment to prevent rupture and death, as it reduces 1-month mortality from 90% to 30% 1.
• The surgical procedure typically involves replacing the damaged section with a synthetic graft, repairing or replacing the aortic valve if needed, and reimplanting coronary arteries.
• For Type B dissections (affecting only the descending aorta), medical management is often preferred initially, using medications like beta-blockers, calcium channel blockers, and vasodilators to control blood pressure (target <120/80 mmHg).
• Endovascular repair using stent grafts is increasingly used for complicated Type B dissections, offering a less invasive alternative to open surgery.

Post-Operative Care

• Post-operative care includes lifelong blood pressure control, regular imaging follow-ups (CT or MRI every 6-12 months initially), and lifestyle modifications including smoking cessation and moderate exercise.
• The procedure carries risks including bleeding, stroke, paralysis, and kidney failure, but without treatment, aortic dissections have a high mortality rate, particularly Type A dissections which have approximately 1-2% mortality per hour if left untreated.

Recent Guidelines

• The 2022 aortic disease guideline-at-a-glance recommends valve-sparing aortic root replacement for patients undergoing aortic root replacement surgery, if the valve is suitable for repair and when performed by experienced surgeons in a Multidisciplinary Aortic Team 1.
• The guideline also suggests that patients with acute type A aortic dissection, if clinically stable, should be considered for transfer to a high-volume aortic center to improve survival.
• The operative repair of type A aortic dissection should entail at least an open distal anastomosis rather than just a simple supracoronary interposition graft 1.

From the Research

Aortic Dissection Repair Overview

• Aortic dissection is a potentially lethal condition that requires immediate diagnostic and therapeutic intervention 2
• Open surgical repair remains the standard of care, but up to 20% of patients are denied surgical therapy due to medical unfitness 2

Surgical Management

• The most effective approach to type A aortic dissection (TAAD) repair is still being debated, with variables such as cannulation technique and conservative versus extensive initial surgery being considered 3
• Acute TAAD is associated with higher incidence of permanent stroke, renal failure, and operative mortality compared to chronic TAAD 3
• Extensive proximal repair can lead to longer perfusion and cross-clamp times, and the need for temporary mechanical support post-operatively 3

Endovascular Repair

• Thoracic endovascular aortic repair (TEVAR) has changed the treatment paradigm for aortic disease involving the descending thoracic aorta and may be a viable option for patients with type A dissection who are not eligible for open surgical repair 2
• TEVAR can significantly reduce short-term mortality for acute type B aortic dissection (ATBAD) 4
• Endovascular repair provides an early surgical benefit for acute type B thoracic aortic dissection, but long-term comparative data is required to give a better understanding of this approach 5
• Endovascular ascending aortic repair in type A dissection has shown acceptable outcomes at short-term follow-up, but lacks mid-late outcomes and reporting consistency 6

Comparison of Open and Endovascular Repair

• Open repair is associated with higher rates of postoperative stroke and paraplegia, as well as higher all-cause operative and 1-year mortality compared to endovascular repair 5
• Endovascular repair has a higher rate of reintervention at 1 year compared to open repair 5
• The rate of all-neurologic events is lower in endovascular repair compared to open repair 5