Management of Aortic Dissection in a 76-Year-Old Male
Immediate surgical intervention is recommended for Type A aortic dissection (involving the ascending aorta), while medical management with aggressive blood pressure control is the initial approach for uncomplicated Type B dissection (limited to descending aorta) in this 76-year-old male patient. 1, 2
Initial Assessment and Stabilization
- Establish intravenous access, obtain blood samples (including CK, troponin, myoglobin, WBC, D-dimer, hematocrit, LDH), perform ECG, and initiate continuous heart rate and blood pressure monitoring 1
- Provide pain relief with intravenous morphine sulfate 1
- Transfer to intensive care unit for appropriate monitoring 1, 2
- Establish invasive blood pressure monitoring with arterial line placement 3, 2
- Check blood pressure in both arms to exclude pseudo-hypotension due to obstruction of an aortic arch branch 3
Immediate Blood Pressure Management
- Reduce systolic blood pressure to 100-120 mmHg using intravenous beta-blockers as first-line therapy (options include propranolol, metoprolol, esmolol, or labetalol) 1, 2
- Target heart rate of ≤60 beats per minute to reduce aortic wall stress by decreasing the force of left ventricular ejection (dP/dt) 3, 2
- For severe hypertension despite beta-blockade, add sodium nitroprusside as a vasodilator (never use vasodilators alone without prior beta-blockade) 1, 3
- In patients with obstructive pulmonary disease, consider calcium channel blockers for blood pressure control 1, 3
Definitive Management Based on Dissection Type
Type A Dissection (Involving Ascending Aorta)
- Urgent surgical consultation and immediate surgical intervention is required 1, 2
- Surgical options include:
- Resection of all aneurysmal aorta and proximal extent of dissection 1
- Aortic valve resuspension for partially dissected aortic root 1
- Aortic root replacement with composite graft or valve-sparing root replacement for extensive dissection of the aortic root 1, 2
- Complete replacement of the entire dissected aorta for DeBakey Type II dissection 1
Type B Dissection (Limited to Descending Aorta)
- Initial medical management with strict blood pressure control is recommended for uncomplicated cases 1, 2
- Emergency intervention (preferably Thoracic Endovascular Aortic Repair - TEVAR) is indicated for complicated Type B dissection presenting with: 1, 2
- Malperfusion syndrome
- Intractable pain
- Rapidly expanding aortic diameter
- Periaortic or mediastinal hematoma
- Dissection occurring in a previously aneurysmatic aorta
Special Considerations for Elderly Patients
- Advanced age (76 years) is a risk factor for aortic dissection and may influence surgical decision-making 4, 5
- Careful assessment of comorbidities and surgical risk is essential in this age group 5
- The benefits of surgical intervention must be weighed against the increased operative risk in elderly patients 5
Monitoring for Complications
- Watch for signs of organ malperfusion (oliguria, neurological symptoms) 3, 5
- If malperfusion develops, blood pressure targets may need to be adjusted higher 3
- Monitor for progression of dissection with repeat imaging 3, 6
Long-Term Management
- For patients managed medically or post-surgery, lifelong beta-blocker therapy is recommended 1, 6
- Regular imaging follow-up is essential to monitor for potential complications such as false lumen expansion or aneurysm formation 2, 6
- Surgical intervention is indicated for secondary aneurysm formation in the dissected aorta, with a diameter threshold of 5-6 cm 1
- Endovascular stenting may be considered if there is a surgical indication and suitable anatomy 1