What is the treatment for type B aortic dissection?

Treatment of Type B Aortic Dissection

For type B aortic dissection, the first-line treatment is medical therapy with pain relief and blood pressure control for uncomplicated cases, while emergency TEVAR (Thoracic Endovascular Aortic Repair) is recommended for complicated cases. 1

Classification and Initial Management

Uncomplicated Type B Aortic Dissection

• Medical therapy is the cornerstone of management 1
  • Aggressive blood pressure control (target 100-120 mmHg systolic)
  • Heart rate control (target 60-80 beats per minute)
  • Beta-blockers are considered first-line therapy 1, 2
  • Adequate pain control
  • Admission to intensive care unit with invasive arterial monitoring 1

Complicated Type B Aortic Dissection

Complications requiring emergency intervention include:

• Malperfusion syndromes (renal, mesenteric, limb, or spinal)
• Rupture or impending rupture
• Rapid aortic expansion
• Persistent pain despite medical therapy
• Refractory hypertension 1, 2

Therapeutic Approach

1. Medical Management (for uncomplicated cases)

• Beta-blockers: First-line therapy to reduce heart rate and blood pressure 1, 2
  • Tight heart rate control (<60 bpm) significantly reduces secondary adverse events 3
• Additional antihypertensives: Calcium channel blockers, ACE inhibitors, or ARBs may be added if needed 2
• IV anti-impulse therapy: Initially, then transition to oral medications after 24 hours if gastrointestinal transit is preserved 1
• Pain management: Adequate analgesia is essential 1

2. Endovascular Treatment (TEVAR)

• First-line therapy for complicated type B dissection 1, 2
• Indications:
  • All complicated cases (malperfusion, rupture, etc.) 1
  • Selected uncomplicated cases with high-risk features in the subacute phase (14-90 days) 1
  • Chronic type B dissection with thoracic aortic diameter ≥60 mm 1
• Benefits:
  • Redirects blood flow to true lumen
  • Induces aortic remodeling
  • Reduces aorta-related mortality and disease progression compared to medical therapy alone 1

3. Open Surgical Repair

• Reserved for cases unsuitable for endovascular repair 2
• Higher morbidity and mortality compared to TEVAR
• May be preferred in young patients with connective tissue disorders 2

Follow-up Protocol

For Medically Managed Patients

• Imaging follow-up at 1,3,6, and 12 months after onset, then yearly if stable 1
• Lifelong blood pressure control
• Intervention recommended when descending thoracic aortic diameter reaches:
  • ≥55 mm in patients with low procedural risk 1
  • ≥60 mm in patients at reasonable surgical risk 1

After TEVAR

• Imaging at 1,6, and 12 months post-operatively, then yearly until the fifth year 1
• Continued blood pressure control
• Monitor for endoleaks, false lumen status, and expansion of residual dissection 2

Special Considerations

Chronic Type B Dissection (>14 days)

• Antihypertensive therapy remains essential 1
• Emergency intervention for acute symptoms of malperfusion, rupture, or disease progression 1
• For thoracoabdominal aortic aneurysms, fenestrated/branched stent grafts may be considered 1

Patients with Connective Tissue Disorders

• Lower threshold for intervention (typically at smaller aortic diameters) 2
• Medical management should be individualized based on shared decision-making 1
• Evaluation at a center with experience in heritable thoracic aortic disease 1

Common Pitfalls to Avoid

• Delaying treatment in cases with malperfusion, which increases mortality 2
• Inadequate blood pressure control, which is the most common cause of dissection extension 2
• Overlooking malperfusion despite stable hemodynamics 2
• Insufficient imaging follow-up, which may miss progressive aortic dilation

The 2024 ESC guidelines represent the most current evidence-based approach to type B aortic dissection management, emphasizing the importance of appropriate patient selection for medical versus interventional strategies 1.