What is the management of Type B aortic dissection?

From the Guidelines

The management of type B aortic dissection should prioritize medical therapy, including pain relief and blood pressure control, with consideration of thoracic endovascular aortic repair (TEVAR) in complicated cases or selected high-risk patients, as recommended by the 2024 ESC guidelines 1.

Initial Management

The initial approach to managing type B aortic dissection involves aggressive medical therapy to control blood pressure and heart rate, aiming to reduce the stress on the aortic wall. This typically includes the use of beta-blockers as the first-line medical therapy, with the goal of achieving a systolic blood pressure of 100-120 mmHg and a heart rate of 60 beats per minute or less, as supported by guidelines 1.

Medical Therapy

• Beta-blockers should be considered as the first-line medical therapy for all patients with acute type B aortic dissection, according to the 2024 ESC guidelines 1.
• Additional medications like nicardipine may be added if beta-blockers alone are insufficient to control blood pressure.
• Pain control with opioid analgesics, such as morphine, is essential for patient comfort and to reduce stress on the aortic wall.

Interventional Management

• TEVAR is recommended as the first-line therapy in patients with complicated acute type B aortic dissection, as stated in the 2024 ESC guidelines 1.
• In patients with uncomplicated acute type B aortic dissection, TEVAR in the subacute phase (between 14 and 90 days) should be considered in selected patients with high-risk features, as per the guidelines 1.

Long-term Management

Long-term management of type B aortic dissection includes:

• Lifelong blood pressure control with a target of less than 130/80 mmHg.
• Regular imaging surveillance, such as CT or MRI, every 6-12 months initially, then annually.
• Lifestyle modifications, including smoking cessation and exercise restrictions, to reduce the risk of disease progression.

This approach is based on the most recent and highest quality evidence available, prioritizing morbidity, mortality, and quality of life outcomes for patients with type B aortic dissection, as recommended by the 2024 ESC guidelines 1.

From the Research

Medical Management

• Medical management is generally the preferred treatment for uncomplicated type B acute aortic dissection cases, centered on the use of antihypertensive agents to alleviate hemodynamic stress on the damaged aortic wall 2.
• Methods of medical management and drug selection are still based mainly on personal experience, expert opinion, and historical observational studies, as randomized controlled studies are lacking 2.
• Guidelines from European, American, and Asian societies recommend the use of medications, but also reaffirm the lack of evidence for therapeutic approaches and targeted medical management 2.

Complicated Type B Aortic Dissection

• Dissections associated with refractory pain, rapid aneurysm formation, malperfusion syndromes, rupture, or impending rupture are categorized as complicated and require intervention to limit mortality 3.
• Thoracic endovascular aortic repair (TEVAR) has emerged as an alternative to open surgical repair for treatment of complicated type B dissection, with relatively low morbidity and mortality compared to open surgical outcomes 3.
• Various societal guidelines propose TEVAR as the treatment of choice for management of complicated disease 3.

Endovascular Therapies

• There has been a recent paradigm shift in the management of type B aortic dissection due to late aneurysmal degeneration, increasing morbidity and mortality in the long term 4.
• Early endovascular intervention, when combined with optimal medical therapy, can prevent late surgical intervention 4.
• Endovascular therapies, such as TEVAR, are being considered for select patients with initially uncomplicated dissection to mitigate the risks of mid and late-term disease progression and aortic-related mortality 3, 4.

Treatment Algorithm

• The decision-making treatment algorithm for management of type B aortic dissection involves considering the presence of complications, such as malperfusion, rupture, or hemodynamic instability 5, 3.
• Uncomplicated type B dissection is generally managed medically, while complicated type B dissection requires intervention, typically with TEVAR 5, 3.