What is the management and treatment approach for acute aortic syndrome?

Management and Treatment of Acute Aortic Syndrome

In patients with acute aortic syndrome (AAS), immediate anti-impulse treatment targeting systolic blood pressure <120 mmHg and heart rate ≤60 beats per minute is recommended as the cornerstone of initial management, along with appropriate surgical or endovascular intervention based on the type and location of the aortic pathology. 1, 2

Initial Assessment and Diagnosis

• ECG-gated CT angiography from neck to pelvis is the first-line imaging technique for suspected AAS, providing crucial information about entry tears, extension, and complications 1
• Focused transthoracic echocardiography (with contrast if feasible) is recommended during initial evaluation to assess for complications 1
• Transesophageal echocardiography is recommended in unstable patients who cannot be transferred for CT and to guide perioperative management 1
• A multiparametric algorithm using the aortic dissection detection-risk score (ADD-RS) with D-dimer is recommended for ruling in or out AAS 1

Medical Management

Initial Anti-Impulse Therapy

• Intravenous beta-blockers (preferably labetalol due to its alpha- and beta-blocking properties) are the first-line agents 1, 2
• If beta-blockers are contraindicated, non-dihydropyridine calcium channel blockers should be considered 1, 2
• Intravenous vasodilators (e.g., dihydropyridine calcium blockers or nitrates) can be added if necessary to achieve target blood pressure 1
• Adequate pain control with intravenous opiates is essential to achieve hemodynamic targets 1, 2

Monitoring

• Invasive monitoring with arterial line and continuous three-lead ECG recording is mandatory 1
• Admission to an intensive care unit is recommended for all patients 1

Transition to Oral Therapy

• In patients managed conservatively who achieve hemodynamic targets with IV therapy, switch to oral beta-blockers and other BP-lowering agents after 24 hours if gastrointestinal transit is preserved 1

Specific Management Based on AAS Type

Type A Aortic Dissection (Involving Ascending Aorta)

• Emergency surgical consultation and immediate surgical intervention is recommended 1
• For patients with extensive destruction of the aortic root, root aneurysm, or known genetic aortic disorder, aortic root replacement with a mechanical or biological valved conduit is recommended 1
• In patients with partially dissected aortic root but no significant aortic valve leaflet pathology, aortic valve resuspension is recommended over valve replacement 1
• Open distal anastomosis is recommended to improve survival and increase false lumen thrombosis rates 1
• Hemi-arch repair is recommended over more extensive arch replacement in patients without intimal tear in the arch or significant arch aneurysm 1

Type B Aortic Dissection (Not Involving Ascending Aorta)

• Medical therapy including pain relief and blood pressure control is recommended for all patients 1
• For complicated acute Type B dissection (malperfusion, rupture, progression), emergency intervention with thoracic endovascular aortic repair (TEVAR) is recommended as first-line therapy 1, 3
• In uncomplicated acute Type B dissection, TEVAR in the subacute phase (14-90 days) should be considered in selected patients with high-risk features 1, 3
• For chronic Type B dissection with descending thoracic aortic diameter ≥60 mm, intervention is recommended in patients at reasonable surgical risk 1

Intramural Hematoma (IMH)

• Medical therapy including pain relief and blood pressure control is recommended for all patients 1
• For Type A IMH, urgent surgery is recommended 1
• For Type B IMH, initial medical therapy under careful surveillance is recommended 1
• For complicated Type B IMH, TEVAR is recommended 1

Penetrating Atherosclerotic Ulcer (PAU)

• Medical therapy including pain relief and blood pressure control is recommended for all patients 1
• For Type A PAU, surgery is recommended 1
• For Type B PAU, initial medical therapy under careful surveillance is recommended 1
• For complicated Type B PAU, endovascular treatment (TEVAR) is recommended 1
• For uncomplicated Type B PAU with high-risk imaging features, endovascular treatment should be considered 1

Traumatic Aortic Injury

• For severe aortic injury (grade 4), immediate repair is recommended 1
• For minimal aortic injury (grades 1 or 2), initial medical therapy under careful clinical and imaging surveillance should be considered 1
• TEVAR is recommended over open surgery for traumatic aortic injury requiring intervention 1

Follow-up After Treatment

Medical Treatment

• For medically treated Type B AAS or IMH: imaging at 1,3,6, and 12 months after onset, then yearly if stable 1
• For medically treated PAU: imaging at 1 month after diagnosis, then every 6 months if stable 1

After Surgical/Endovascular Treatment

• After open surgery for AAS: imaging by CT and TTE within 6 months, then CT at 12 months and yearly if stable 1
• After TEVAR: follow-up imaging at 1 and 12 months post-operatively, then yearly until the fifth post-operative year if no abnormalities are documented 1

Common Pitfalls to Avoid

• Delaying beta-blockers in favor of vasodilators, which can worsen dissection through reflex tachycardia 2
• Excessive blood pressure lowering that may compromise organ perfusion 2
• Failing to monitor blood pressure in both arms (may miss pseudo-hypotension due to obstruction of an aortic arch branch) 2
• Neglecting pain control, which can contribute to hypertension 2
• Delaying imaging in patients with high clinical suspicion 4