What is the management plan for patients with aortic diseases, such as aortic aneurysms or dissections?

Management of Aortic Diseases

Emergency surgical intervention is recommended for patients with acute Type A aortic dissection, while medical therapy with close monitoring is the initial approach for uncomplicated Type B aortic dissection, with TEVAR (thoracic endovascular aortic repair) indicated for complicated cases. 1

Diagnosis of Aortic Diseases

The diagnostic approach for suspected aortic diseases should follow these steps:

1. Initial Imaging: ECG-gated CT angiography from neck to pelvis is the first-line imaging technique for suspected acute aortic syndrome, providing detailed information about entry tears, extension, and complications 1

2. Additional Assessment:

   • Focused transthoracic echocardiography (TTE) during initial evaluation
   • Transesophageal echocardiography (TOE) to guide perioperative management and detect complications
   • Use of the Aortic Dissection Detection Risk Score (ADD-RS) for risk stratification

Management of Acute Aortic Syndromes

Immediate Medical Management

For all acute aortic syndromes:

• Immediate anti-impulse therapy targeting SBP <120 mmHg and heart rate ≤60 bpm 1
• First-line agents: IV beta-blockers (e.g., labetalol)
• Second-line: IV vasodilators (calcium channel blockers or nitrates) if needed
• Invasive arterial monitoring and ICU admission
• Adequate pain control
• After 24 hours, transition to oral beta-blockers if hemodynamically stable 1

Type A Aortic Dissection (Involving Ascending Aorta)

• Emergency surgical intervention is recommended 1

• Surgical approach based on extent of aortic involvement:

  • For extensive aortic root destruction/aneurysm: Aortic root replacement with mechanical or biological valved conduit 1
  • For partially dissected aortic root without valve pathology: Aortic valve resuspension 1
  • Open distal anastomosis to improve survival and false lumen thrombosis 1
  • Hemi-arch repair for cases without arch tear or aneurysm 1

• For patients with malperfusion (cerebral, mesenteric, limb, renal): Immediate aortic surgery 1

Type B Aortic Dissection (Involving Descending Aorta)

• Uncomplicated cases: Initial medical therapy with pain relief and blood pressure control 1

  • Consider TEVAR in subacute phase (14-90 days) for high-risk features 1

• Complicated cases (malperfusion, rupture, progression):

  • Emergency TEVAR as first-line therapy 1
  • For chronic TBAD with descending thoracic aortic diameter ≥60 mm: Intervention recommended 1
  • For chronic TBAD with diameter ≥55 mm: Consider intervention in low-risk patients 1

Intramural Hematoma (IMH)

• Medical therapy including pain relief and blood pressure control for all IMH patients 1
• Type A IMH: Urgent surgery 1
• Type B IMH: Initial medical therapy with careful surveillance 1
• Complicated Type B IMH: TEVAR 1

Penetrating Atherosclerotic Ulcer (PAU)

• Medical therapy for all PAU patients 1
• Type A PAU: Surgery 1
• Type B PAU: Initial medical therapy with surveillance 1
• Complicated Type B PAU: TEVAR 1
• Uncomplicated Type B PAU with high-risk imaging features: Consider TEVAR 1

Traumatic Aortic Injury

• Severe injury (grade 4): Immediate repair 1
• Moderate injury (grade 3): Repair 1
• Minimal injury (grades 1-2): Medical therapy with surveillance 1
• TEVAR preferred over open surgery when intervention required 1

Follow-up After Treatment

After TEVAR for Acute Aortic Syndrome

• Imaging at 1,6, and 12 months post-operatively, then yearly until fifth year 1

Medically Treated Type B Dissection or IMH

• Imaging at 1,3,6, and 12 months after onset, then yearly if stable 1

Medically Treated PAU

• Imaging at 1 month after diagnosis, then every 6 months if stable 1

After Open Surgery

• Consider imaging by CCT and TTE within 6 months, then CCT at 12 months and yearly thereafter 1

Special Considerations for Heritable Thoracic Aortic Disease

• Patients with known or suspected syndromic or non-syndromic heritable thoracic aortic disease should be evaluated at specialized centers 1

• Genetic testing recommendations:

  • Gather family history for at least three generations 1
  • Genetic counseling and testing for patients with risk factors for heritable disease 1
  • Cascade testing of at-risk relatives when pathogenic variants identified 1

Common Pitfalls and Caveats

1. Delayed diagnosis: Maintain high index of suspicion for aortic dissection in patients with sudden-onset severe chest or back pain

2. Inappropriate imaging: Always use ECG-gated CT from neck to pelvis for suspected acute aortic syndrome

3. Inadequate blood pressure control: Failure to achieve target SBP <120 mmHg and heart rate ≤60 bpm increases risk of progression

4. Pericardiocentesis risks: In Type A dissection with tamponade, pericardiocentesis has been associated with recurrent bleeding and mortality; withdraw just enough fluid to restore perfusion if surgery cannot be performed immediately 1

5. Inadequate follow-up: Strict adherence to imaging surveillance protocols is essential to detect complications early

6. Overlooking genetic factors: Always consider heritable conditions in patients with aortic disease, especially with family history or young age at presentation