From the Guidelines
The primary treatment for Type B aortic dissection involves medical management, with thoracic endovascular aortic repair (TEVAR) recommended as the first-line therapy for complicated cases, as stated in the 2024 ESC guidelines 1.
Medical Management
The initial treatment focuses on aggressive blood pressure control using intravenous beta-blockers, such as labetalol or esmolol, targeting a systolic blood pressure of 100-120 mmHg, and pain control with IV opioids like morphine.
- Medical therapy, including pain relief and blood pressure control, is recommended in all patients with acute Type B aortic dissection (TBAD) 1.
- Beta-blockers (BBs) should be considered as the first-line medical therapy in patients with acute TBAD 1.
Surgical Intervention
Surgical intervention or endovascular repair is indicated for complications including rupture, malperfusion syndrome, uncontrollable pain, uncontrollable hypertension, or rapid aortic expansion.
- In patients with complicated acute TBAD, emergency intervention is recommended, with TEVAR as the first-line therapy 1.
- For uncomplicated cases, the medical approach is preferred due to the risks associated with surgery in the thoracic aorta below the left subclavian artery.
Long-term Management
Long-term management includes lifetime blood pressure control, smoking cessation, regular imaging surveillance, and cholesterol management to prevent progression of the dissection.
- The use of beta-blockers has been associated with improved survival in patients with aortic dissections, as observed in studies 1.
- Regular follow-up with CT or MRI scans is essential for monitoring the progression of the dissection and adjusting treatment accordingly.
From the Research
Treatment Overview
- The initial management goal for type B aortic dissection (TBAD) is to prevent aortic rupture, propagation of the dissection, and symptoms by reducing the heart rate and blood pressure 2.
- Uncomplicated TBAD patients require prompt medical management to prevent aortic dilatation or rupture during subsequent follow-up 2.
- Complicated TBAD patients require immediate invasive management to prevent death or injury caused by rupture or malperfusion 2.
Medical Management
- Medical management is generally the preferred treatment for uncomplicated type B acute aortic dissection cases, often centered on the use of antihypertensive agents 3.
- Beta-blockers are commonly used as first-line therapy to decrease aortic wall stress, but there is no randomized controlled trial (RCT) evidence to support this recommendation 4.
- Other antihypertensive medications, such as calcium channel blockers, angiotensin-converting enzyme inhibitors, or angiotensin II receptor blockers, may also be used 4.
Endovascular Repair
- Thoracic endovascular aortic repair (TEVAR) has become a popular treatment option for TBAD, with a fourfold increase in early survival in complicated TBAD 2.
- TEVAR is recommended for acute TBAD with complications, and for uncomplicated TBAD with high-risk features in the subacute phase 5.
- The introduction of thoracic stent-grafts has shifted the management of TBAD from surgical to endovascular repair 2.
Surgical Repair
- Open surgical repair is seldom required and reserved only for select cases 5.
- Hybrid approaches, combining open and endovascular repair, have had promising results for more challenging aortic dissection patients with involvement of the aortic arch 2.