What is the treatment for aortic dissection?

Treatment of Aortic Dissection

Immediate surgical intervention is required for Type A aortic dissection, while Type B dissection is managed medically unless complications arise. 1

Classification and Initial Management Approach

Aortic dissection is classified into two main types that determine treatment:

• Type A (Stanford): Involves the ascending aorta

  • Requires immediate surgical intervention
  • Mortality rate of 50% within 48 hours if not operated 1

• Type B (Stanford): Limited to descending aorta

  • Initially managed medically unless complications develop
  • Complications requiring intervention: rupture, malperfusion, refractory pain, rapid expansion

Type A Aortic Dissection Management

Surgical Management (Class I recommendation)

• Immediate surgical repair is mandatory 1
• Goals: prevent aortic rupture, relieve pericardial tamponade, address aortic regurgitation
• Surgical approach:
  • Resection of aneurysmal aorta and proximal extent of dissection
  • Aortic valve management options:
    • Valve resuspension if root is normal
    • Composite graft replacement if root is dilated or extensively dissected
    • Valve-sparing root replacement in appropriate cases 1

Malperfusion Complications

• In patients with malperfusion (cerebral, mesenteric, renal, limb), immediate surgery is still recommended 1
• For mesenteric malperfusion, consider angiographic evaluation before or after surgery 1
• For cerebral malperfusion or non-hemorrhagic stroke, immediate surgery should be considered 1

Special Considerations

• Age alone should not exclude patients from surgical treatment 1
• Even patients with unfavorable presentations benefit from surgery over medical management
• In-hospital mortality is significantly lower with surgical management compared to medical treatment, even in octogenarians 1

Type B Aortic Dissection Management

Uncomplicated Type B

• Initial management is medical with optimal blood pressure control
• Consider TEVAR (Thoracic Endovascular Aortic Repair) in the subacute phase (14-90 days) for patients with high-risk features 1

Complicated Type B

• Complications include:
  • Aortic rupture/impending rupture
  • Malperfusion syndromes
  • Refractory pain
  • Rapid aortic expansion
  • Refractory hypertension
• Endovascular therapy (TEVAR) is first-line treatment if anatomy is favorable 1
• Open surgery reserved for unsuitable cases or when endovascular approach fails

Chronic Type B

• Intervention recommended when descending thoracic aortic diameter ≥60 mm 1
• Consider intervention when diameter ≥55 mm in low-risk patients 1
• Fenestrated/branched stent grafts may be considered for thoracoabdominal aneurysms 1

Medical Management

• Aggressive blood pressure control is essential for all patients
• Target systolic blood pressure: 100-120 mmHg
• First-line agents:
  • Beta-blockers to reduce shear stress on the aortic wall
  • Additional antihypertensives as needed
• Pain control
• Close monitoring for signs of progression or complications

Follow-up Protocol

For medically treated Type B dissection:

• Imaging at 1,3,6, and 12 months after onset
• Yearly thereafter if stable 1

After surgical repair:

• Imaging within 6 months
• Then at 12 months and yearly if stable
• Consider extending to every 2 years after 5 years of stability 1

Common Pitfalls to Avoid

1. Delayed diagnosis: Maintain high index of suspicion in patients with sudden-onset severe chest or back pain
2. Pericardiocentesis: Avoid in dissection-related hemopericardium except as a life-saving bridge to surgery 1
3. Inadequate blood pressure control: Failure to control hypertension increases risk of extension and rupture
4. Incomplete surgical repair: Leaving residual dissected aorta increases risk of late complications
5. Inadequate follow-up: Regular imaging surveillance is essential to detect late complications

Special Situations

• Intramural Hematoma (IMH): Treat similarly to aortic dissection based on location
• Penetrating Atherosclerotic Ulcer (PAU): Consider endovascular treatment for type B with high-risk features 1
• Traumatic Aortic Injury: Immediate repair for severe injury (grade 4); medical therapy with surveillance for minimal injury 1

The management of aortic dissection requires a rapid, decisive approach based on accurate classification and assessment of complications, with immediate surgical intervention for Type A dissection and selective intervention for Type B dissection.