What is the treatment for aortic dissection in the United States (U.S.)?

From the Guidelines

The treatment for aortic dissection in the United States typically involves immediate medical stabilization followed by either surgical or endovascular intervention, with the goal of reducing morbidity, mortality, and improving quality of life. The most recent and highest quality study 1 recommends that patients with acute aortic disease, including dissection, should have their systolic blood pressure and heart rate immediately reduced to 120 mmHg or lower and 60 beats per minute or less, respectively, to reduce aortic wall stress and disease progression.

Key Considerations

• Beta-blockers are considered first-line treatment for acute aortic dissection, with esmolol being a preferred option due to its ultra-short acting properties, which can be used together with vasodilating agents such as nitroprusside or clevidipine 1.
• For Type A dissections, emergency open surgical repair is the standard treatment, which includes removing the damaged section of aorta and replacing it with a synthetic graft, as it reduces 1-month mortality from 90% to 30% 1.
• For Type B dissections, medical management is often the first approach, using medications like beta-blockers and vasodilators to control blood pressure and heart rate, with a target systolic blood pressure of 100-120 mmHg and heart rate below 60 beats per minute.
• Pain management with opioid analgesics is also essential, as it helps to reduce the stress response and prevent further progression of the dissection.
• Long-term management includes lifelong blood pressure control with medications like beta-blockers, ACE inhibitors, or ARBs, along with regular imaging surveillance every 6-12 months to monitor for potential complications.

Treatment Approach

• The treatment approach should be individualized based on the type and location of the dissection, as well as the patient's overall health status and comorbidities.
• Surgical intervention is generally recommended for Type A dissections, while medical management may be sufficient for uncomplicated Type B dissections.
• Endovascular repair with stent grafts is increasingly preferred over open surgery for complicated Type B dissections with organ malperfusion or rupture, as it is a less invasive procedure with potentially lower morbidity and mortality.

From the Research

Treatment Overview

The treatment for aortic dissection in the United States (U.S.) involves a combination of medical and surgical approaches, depending on the type and severity of the dissection.

• For type A dissections, surgical repair is essential due to high mortality rates with expectant therapy alone 2.
• For type B dissections, medical management is successful in most patients, although a subset with complications or early dilation may benefit from newer endovascular techniques 2.

Medical Management

Medical therapy with aggressive blood pressure lowering is recommended for patients with acute aortic dissection, when they are not indicated for emergency surgery 3.

• Beta-blockers are the "medications of choice" for reducing systolic blood pressure and heart rate in non-surgical patients with type A aortic dissection 4.
• Aggressive measures to lower the systemic blood pressure and its rate of increase (dP/dt), usually with intravenous beta-blockade in combination with sodium nitroprusside, should be instituted immediately 5.

Surgical Intervention

Surgical treatment of aortic dissection involving the ascending aorta necessitates immediate surgical repair 6.

• Patients with type B aortic dissection who have critical complications have higher early mortality than that in patients without complications, and may benefit from thoracic endovascular aortic repair 3.
• Surgical repair is essential for type A dissections, as mortality rates approach 50% at 48 hours with expectant therapy alone 2.

Endovascular Techniques

There is a growing experience with catheter-based techniques, including fenestration, stenting, and endoluminal graft insertion, for the management of selected patients with acute dissection 5.

• Recent advances in thoracic endovascular aortic repair can improve the clinical outcomes in patients with complicated type B aortic dissection 3.