What is the management approach for acute aortic syndrome?

Management of Acute Aortic Syndrome

Acute aortic syndrome requires immediate aggressive medical therapy to control blood pressure and heart rate, with emergency surgical intervention for type A dissection and thoracic endovascular repair (TEVAR) for complicated type B dissection. 1

Initial Diagnostic Approach

ECG-gated CT angiography from neck to pelvis is the first-line imaging modality for suspected acute aortic syndrome, providing critical information about entry tears, extension, malperfusion, dilatation, and rupture. 1, 2

• In hemodynamically unstable patients who cannot be transferred for CT, transesophageal echocardiography (TOE) should be performed for diagnosis and evaluation. 1
• Focused transthoracic echocardiography with contrast (if feasible) is essential during initial evaluation to assess for complications. 1, 2
• A multiparametric algorithm using the aortic dissection detection-risk score (ADD-RS) is recommended for ruling in or out acute aortic syndrome. 1, 2

Immediate Medical Management

All patients with acute aortic syndrome require immediate anti-impulse therapy targeting systolic blood pressure <120 mmHg and heart rate ≤60 beats per minute. 1

First-Line Pharmacotherapy

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

Critical Care Monitoring

• Invasive arterial line monitoring and continuous three-lead ECG recording are required. 1
• Admission to an intensive care unit is mandatory. 1
• After 24 hours, switch to oral beta-blockers if gastrointestinal transit is preserved and hemodynamic targets are achieved. 1

Important caveat: In cases of spinal ischemia or concomitant brain injury, maintain higher mean arterial pressure rather than the standard target. 1

Type-Specific Intervention Strategies

Type A Acute Aortic Dissection (Ascending Aorta)

Emergency surgical consultation and immediate surgical intervention is mandatory for all type A dissections. 1, 2

Surgical Approach

• Hemi-arch repair is recommended in patients without an intimal tear in the arch or significant arch aneurysm, rather than more extensive arch replacement. 1
• Open distal anastomosis is recommended to improve survival and increase false lumen thrombosis rates. 1
• Aortic valve resuspension is preferred over valve replacement in patients with partially dissected aortic root but no significant valve leaflet pathology. 1
• Aortic root replacement with mechanical or biological valved conduit is required in patients with extensive root destruction, root aneurysm, or known genetic aortic disorder. 1
• Transfer to a high-volume aortic center with a multidisciplinary team should be considered if accomplished without significant surgical delay. 1

Malperfusion Management in Type A Dissection

Immediate aortic surgery is recommended for all patients presenting with malperfusion (cerebral, mesenteric, lower limb, or renal). 1

• In patients with cerebral malperfusion or non-hemorrhagic stroke, immediate aortic surgery should be considered to improve neurological outcomes and reduce mortality. 1, 3
• For clinically significant mesenteric malperfusion syndrome, immediate invasive angiographic diagnostics to evaluate percutaneous malperfusion repair before or directly after aortic surgery should be considered in centers with expertise. 1

Type B Acute Aortic Dissection (Descending Aorta)

Medical therapy including pain relief and blood pressure control is recommended in all patients with acute type B dissection. 1

Complicated Type B Dissection

Emergency intervention with TEVAR is recommended as first-line therapy for complicated acute type B dissection (presence of rupture, malperfusion, refractory pain, uncontrolled hypertension, or rapid aortic expansion). 1, 2, 3

Uncomplicated Type B Dissection

• TEVAR in the subacute phase (between 14 and 90 days) should be considered in selected patients with high-risk features to prevent late complications. 1, 2
• Initial medical therapy under careful surveillance is the standard approach for uncomplicated cases. 1

Intramural Hematoma (IMH)

Medical therapy including pain relief and blood pressure control is recommended for all patients with IMH. 1

• Type A IMH requires urgent surgery. 1
• Type B IMH should be managed with initial medical therapy under careful surveillance. 1
• Repetitive imaging with CT is essential for monitoring progression. 1

Chronic Type B Aortic Dissection

• Antihypertensive therapy is required in all patients with chronic type B dissection. 1
• Emergency intervention is recommended for acute symptoms of malperfusion, rupture, or disease progression. 1
• Treatment is recommended when descending thoracic aortic diameter reaches ≥60 mm in patients at reasonable surgical risk. 1, 2

Follow-Up Surveillance

After Medical Treatment (Type B or IMH)

Imaging at 1,3,6, and 12 months after onset, then yearly if stable. 2

After Open Surgery

• CT and transthoracic echocardiography within 6 months. 2, 3
• CT at 12 months and yearly thereafter if stable. 2, 3

After TEVAR

• Follow-up imaging at 1 and 12 months post-operatively. 2
• Yearly imaging until the fifth post-operative year if no abnormalities are documented. 2
• After 5 post-operative years without complications, continuing long-term follow-up by CT every 5 years should be considered. 1

Critical pitfall: Acute aortic syndrome should be considered a lifelong disease affecting the entire aorta, requiring indefinite surveillance and antihypertensive therapy. 4