What is the management and treatment for a patient with aortic dissection?

Management and Treatment of Aortic Dissection

The management of aortic dissection requires immediate intervention with type-specific treatment: surgical repair for Type A (ascending aorta) dissection and primarily medical management for uncomplicated Type B (descending aorta) dissection, with endovascular intervention for complicated Type B cases. 1, 2

Initial Stabilization and Assessment

• Transfer the patient to an intensive care unit for appropriate monitoring with invasive blood pressure monitoring via arterial line (preferably right radial artery) 1, 2
• Provide adequate pain control with morphine sulfate to reduce sympathetic stimulation 1, 2
• Obtain diagnostic imaging immediately - CT angiography, transesophageal echocardiography (TEE), or MRI depending on institutional capabilities and patient stability 1, 2
• For profoundly unstable patients, perform bedside transthoracic echocardiography (TTE) to identify cardiac tamponade or other immediate life-threatening complications 1

Blood Pressure and Heart Rate Control

• Target systolic blood pressure between 100-120 mmHg and heart rate ≤60 beats per minute to reduce shear stress on the aortic wall 1, 2
• Administer intravenous beta-blockers as first-line therapy:
  • Propranolol (0.05-0.15 mg/kg every 4-6 hours) 1
  • Esmolol (loading dose 0.5 mg/kg over 2-5 min, followed by infusion of 0.10-0.20 mg/kg/min) 1, 2
  • Labetalol (combined alpha and beta blockade) is particularly useful 2, 3
• If beta-blockers alone are insufficient for blood pressure control, add vasodilators (never use vasodilators without prior beta-blockade) 1, 2
  • Sodium nitroprusside starting at 0.25 μg/kg/min and titrate to effect 1, 3
• For patients with beta-blocker contraindications (asthma, bradycardia, heart failure), consider non-dihydropyridine calcium channel blockers like verapamil or diltiazem 1, 2

Type-Specific Management

Type A Dissection (Involving Ascending Aorta)

• Immediate surgical consultation and emergency surgical repair is indicated 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 root dissection 1
• For patients with hemopericardium and cardiac tamponade who cannot survive until surgery, perform limited pericardiocentesis withdrawing just enough fluid to restore perfusion 1

Type B Dissection (Involving Descending Aorta Only)

• Uncomplicated cases: Medical management with aggressive blood pressure and heart rate control 1, 2
• Complicated cases requiring intervention (preferably TEVAR - Thoracic Endovascular Aortic Repair): 1, 2
  • Malperfusion syndrome
  • Intractable pain
  • Rapidly expanding aortic diameter
  • Periaortic or mediastinal hematoma
  • Dissection in previously aneurysmal aorta

Special Considerations

• For patients with hypotension, consider:
  • Volume administration titrated to improvement of blood pressure as first approach 1
  • Avoid vasopressors if possible as they may cause further false lumen propagation 1
  • Evaluate for cardiac tamponade, severe aortic regurgitation, true lumen obstruction, or contained rupture 1
• In patients with hereditary diseases (Marfan syndrome, Ehlers-Danlos syndrome), lifelong beta-blocker therapy is recommended 2
• For pregnant patients, management requires a multidisciplinary team at specialized centers 2

Long-term Management

• Transition from intravenous to oral beta-blockers after 24 hours of hemodynamic stability 2, 3
• Target long-term blood pressure <135/80 mmHg 3
• Regular imaging follow-up to monitor for complications such as false lumen expansion or aneurysm formation 2, 3
• Lifelong medical therapy with beta-blockers and appropriate serial imaging 4

Common Pitfalls to Avoid

• Delaying diagnosis and treatment - mortality increases by 1-2% per hour in untreated Type A dissection 5
• Using vasodilators without prior beta-blockade, which can increase aortic wall stress through reflex tachycardia 2, 3
• Performing complete pericardiocentesis for dissection-related hemopericardium, which may lead to recurrent bleeding 1
• Excessive blood pressure lowering, which may compromise organ perfusion 3
• Neglecting regular imaging follow-up to detect disease progression 2, 3