What is the treatment for type A aortic dissection?

Treatment for Type A Aortic Dissection

Immediate emergency surgical intervention is the definitive treatment for type A aortic dissection to prevent aortic rupture, cardiac tamponade, and death. 1

Initial Management Before Surgery

• Pain control: IV opioid analgesics titrated to effect with regular pain assessment 2
• Blood pressure control: Target systolic BP 100-120 mmHg and heart rate 60-80 bpm using IV beta-blockers as first-line therapy 2
• Continuous monitoring: Assess for end-organ perfusion and malperfusion syndromes affecting renal function, mesenteric circulation, and lower extremity perfusion 2

Surgical Management Algorithm

Step 1: Assess Aortic Root and Valve Condition

• Normal aortic root size with intact valve and no commissural detachment:

  • Tubular graft anastomosed to the sinotubular ridge (supracoronary graft) 1

• Detached valve commissures but salvageable valve:

  • Valve resuspension with pledgetted transmural mattress sutures
  • Supracoronary graft placement 1

• Ectatic proximal aorta or pathological valve changes (including Marfan syndrome):

  • Composite graft replacement (aortic valve plus ascending aortic tube graft) 1

Step 2: Surgical Approach

• Standard approach through median sternotomy 1
• Extracorporeal circulation established via femoral artery and right atrium cannulation 1
• Hypothermic circulatory arrest for distal anastomosis 1

Step 3: Reconstruction Technique

• Dissected aorta is completely divided at the sinotubular junction 1
• Reconstitution of dissected layers using either:
  • Gelatin resorcinol formaldehyde (GRF) glue technique (preferred for time-saving and easier application) 1
  • Traditional technique with teflon felt strips placed inside and outside the dissected perimeter 1

Step 4: Determine Extent of Repair

• If arch is involved or previously aneurysmatic:
  • Subtotal or total arch replacement may be required
  • May include reconnection of supraaortic vessels during hypothermic circulatory arrest 1
• For extensive dissections:
  • Consider hybrid prosthesis techniques (e.g., "frozen elephant trunk") for better long-term outcomes 3

Postoperative Management

• Imaging schedule:
  • Within 1 month post-procedure
  • Every 6 months for the first year
  • Annually thereafter 2
• Monitoring for:
  • False lumen status
  • Endoleaks
  • Expansion of residual dissection 2
• Blood pressure control: Critical to prevent dissection extension 2

Outcomes and Prognosis

• Hospital mortality rate is approximately 15% with immediate surgical treatment 4
• Risk factors for poor outcomes include:
  • Age >60 years
  • Hemodynamic compromise
  • Absence of hypertension
  • New neurological symptoms 4
• 5-year and 10-year survival rates of 71% and 54% respectively 4

Common Pitfalls to Avoid

• Delayed diagnosis: Type A dissection is a surgical emergency requiring immediate intervention 5
• Inadequate blood pressure control: Most common cause of dissection extension 2
• Overlooking malperfusion: Can occur despite stable hemodynamics 2
• Limited resection: More extensive primary resections may improve remote results by promoting false lumen thrombosis 3

The European Society of Cardiology guidelines strongly recommend emergency surgery for all type A aortic dissections (Class I recommendation, Level of Evidence C) to avoid tamponade and aortic rupture 1.