What is the treatment for aortic dissection?

Aortic Dissection Treatment

Aortic dissection treatment is determined by anatomic classification: Type A dissections require emergency surgical intervention to prevent rupture and death, while uncomplicated Type B dissections are managed medically with aggressive blood pressure and heart rate control. 1, 2

Immediate Stabilization (All Types)

Transfer immediately to an intensive care unit with invasive arterial line monitoring and continuous ECG. 1, 2

• Administer intravenous beta-blockers as first-line therapy (propranolol, esmolol, or labetalol) targeting systolic blood pressure 100-120 mmHg and heart rate ≤60 beats per minute 1, 2, 3
• Provide pain control with morphine sulfate to reduce sympathetic stimulation 1, 2
• If beta-blockers alone are insufficient for blood pressure control, add sodium nitroprusside—never use vasodilators without prior beta-blockade as this increases aortic wall stress through reflex tachycardia 1, 3
• If beta-blockers are contraindicated, use non-dihydropyridine calcium channel blockers for heart rate control 2
• Obtain urgent diagnostic imaging with CT angiography, transesophageal echocardiography, or MRI depending on institutional capabilities and patient stability 1

Type A Dissection Management

Emergency surgical intervention is mandatory for Type A dissections to prevent aortic rupture, pericardial tamponade, and relieve aortic regurgitation. 1, 2, 3

Surgical Approach and Techniques

• Access the ascending aorta and transverse aortic arch through median sternotomy 1
• Surgical options include composite graft implantation in the ascending aorta with or without coronary artery reimplantation 4, 2
• When the aortic root is normal and the valve is intact, supracommisural graft implantation is appropriate 4, 2
• Valve resuspension is adequate in approximately 50% of patients with chronic Type A dissection when commissures are detached 4, 2
• Subtotal or total arch replacement may be necessary when dissection extends to the arch, including reconnection of supraaortic vessels during hypothermic circulatory arrest 4, 2
• Conjoin dissected aortic layers using teflon felt strips or gelatin resorcinol formaldehyde glue (GRF-glue) to create a firm, leak-proof anastomosis 4, 1

Important Surgical Considerations

The rate of reoperation for Type A dissection is approximately 10% at 5 years and up to 40% at 10 years after primary surgery, with even higher risk in Marfan syndrome patients. 1, 2

Type B Dissection Management

Uncomplicated Type B Dissections

Uncomplicated Type B dissections are managed medically with aggressive blood pressure and heart rate control, as there is no proven superiority of surgical or endovascular intervention over medical therapy in this setting. 4, 1

• Continue intravenous beta-blockers with the same hemodynamic targets as initial stabilization 1, 3
• Maintain close clinical and radiologic assessment of the entire thoracoabdominal aorta to detect complications early 5

Complicated Type B Dissections

Surgical or endovascular intervention is indicated for complicated Type B dissections presenting with persistent or recurrent pain, early expansion of aortic diameter, peripheral ischemic complications, rupture, or signs of impending rupture. 1, 3

• Thoracic endovascular aortic repair (TEVAR) is the preferred intervention for complicated Type B dissections, aiming to cover the primary entry tear and redirect blood flow to the true lumen 1, 3
• For surgical repair, use a posterolateral chest incision to access the descending aorta, with most surgeons employing extracorporeal circulation via left heart bypass 4, 1, 2
• Replace affected portions with a tubular graft of appropriate length and size under moderate hypothermia with equalized perfusion pressures 4, 1, 2

Interventional Catheter-Based Therapy

For malperfusion syndromes with dynamic obstruction of branch vessels:

• Perform balloon fenestration of the dissecting membrane plus stenting of the aortic true lumen 4
• Stent obstructed branch artery origins for static obstruction 4
• Create fenestration to provide re-entry tear for dead-end false lumen 4
• Use covered stents to seal the entry tear and enlarge compressed true lumen 4

Long-Term Management

• Transition from intravenous to oral beta-blockers after 24 hours of hemodynamic stability 1, 2
• Target long-term blood pressure <135/80 mmHg 1
• Lifelong beta-blocker therapy is mandatory for patients with hereditary connective tissue disorders such as Marfan syndrome or Ehlers-Danlos syndrome 1, 2
• Perform regular imaging surveillance to monitor for false lumen expansion or aneurysm formation 1, 2, 3
• Consider reoperation when the dissected aorta becomes aneurysmatic (5-6 cm in diameter for Type A, 6.0 cm for Type B) 1, 2, 3

Critical Pitfalls to Avoid

• Never administer vasodilators alone without prior beta-blockade—this causes reflex tachycardia that increases aortic wall stress 1, 3
• Avoid dihydropyridine calcium channel blockers without beta-blockers due to risk of reflex tachycardia 1, 3
• In malperfusion scenarios, higher blood pressure may be tolerated temporarily to optimize perfusion to threatened organs 2
• Despite aggressive medical treatment, hospital mortality during conservative treatment of Type B dissection remains approximately 17.6%, with rupture and thoracoabdominal malperfusion as main causes of death 5
• Repeat sternotomy for Type A reoperation requires extreme care as the aorta is usually unprotected by pericardium 2