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 typically managed medically unless complications arise. 1

Classification and Initial Management

Aortic dissection is classified into two main types:

Type A Dissection (Involving Ascending Aorta)

• Immediate surgical management is mandatory due to high mortality (50% within 48 hours if not operated) 1
• Surgery reduces 1-month mortality from 90% to 30% 1
• Even in elderly patients or those with comorbidities, surgical management shows better outcomes than medical treatment 1

Type B Dissection (Involving Descending Aorta Only)

• Primary management is medical therapy for uncomplicated cases 1
• Surgical or endovascular intervention is indicated for complicated cases 1

Management Algorithm

For Type A Aortic Dissection:

1. Immediate surgical intervention 1

   • Resect aneurysmal aorta and proximal extent of dissection
   • For partially dissected aortic root: valve resuspension
   • For extensive dissection of aortic root: root replacement with composite graft or valve-sparing procedure
   • For DeBakey Type II: replace entire dissected aorta

2. Management of complications:

   • For malperfusion (cerebral, mesenteric, lower limb, renal): immediate aortic surgery 1
   • For cerebral malperfusion/non-hemorrhagic stroke: immediate aortic surgery 1
   • For mesenteric malperfusion: consider angiographic diagnostics for percutaneous repair before or after surgery 1

For Type B Aortic Dissection:

1. Uncomplicated cases:

   • Medical management with aggressive blood pressure control 1
   • Consider TEVAR (Thoracic Endovascular Aortic Repair) in subacute phase (14-90 days) for patients with high-risk features 1

2. Complicated cases requiring intervention:

   • Persistent pain despite medical therapy
   • Rapid aortic expansion
   • Periaortic/mediastinal hematoma (signs of rupture)
   • Malperfusion of vital organs
   • TEVAR is first-line treatment if anatomy is favorable 1
   • Open surgical repair for unsuitable anatomy 1

Medical Management Components

1. Blood pressure control:

   • Target systolic BP: 100-120 mmHg 2
   • Target heart rate: 60-80 beats/min 2
   • First-line agents: Beta-blockers (reduce force of left ventricular ejection)
   • Second-line: Vasodilators (only after adequate beta-blockade)

2. Pain management:

   • Adequate analgesia is essential
   • Persistent pain may indicate progression or complications

Follow-up Protocol

• For medically treated Type B dissection:
  • Imaging at 1,3,6, and 12 months, then yearly if stable 1
• After surgical repair:
  • Imaging within 6 months, at 12 months, then yearly 1
  • If stable for 5 years, consider imaging every 2 years 1

Special Considerations

• Pericardial tamponade: Avoid pericardiocentesis if possible; if necessary, withdraw only enough fluid to restore perfusion until definitive surgery 1
• Intramural hematoma: Treat similar to aortic dissection based on location 1
• Chronic dissection: For Type B with diameter ≥60 mm, intervention is recommended; for ≥55 mm, intervention should be considered in low-risk patients 1

Pitfalls to Avoid

1. Delayed diagnosis: Maintain high index of suspicion in patients with sudden-onset severe chest or back pain
2. Inappropriate use of vasopressors: May worsen dissection by increasing shear stress
3. Pericardiocentesis: Associated with recurrent bleeding and mortality; avoid if possible until surgery
4. Inadequate imaging: CT, MRI, or transesophageal echocardiography are essential for accurate diagnosis
5. Failure to recognize malperfusion: Can lead to irreversible organ damage

The treatment approach to aortic dissection must be swift and decisive, with immediate surgical consultation regardless of dissection type, as complications can develop unpredictably 1.