What is the treatment for type A aortic dissection?

Treatment of Type A Aortic Dissection

Emergency surgical intervention is the definitive treatment for acute Type A aortic dissection and must be performed immediately to prevent fatal complications including aortic rupture, cardiac tamponade, and death. 1

Immediate Medical Stabilization (Pre-operative)

All patients require aggressive medical management while preparing for surgery:

• Initiate intravenous beta-blockers immediately (labetalol, esmolol, or propranolol) as first-line agents to target systolic blood pressure <120 mmHg and heart rate ≤60 beats per minute 1, 2
• Add intravenous vasodilators (dihydropyridine calcium blockers or nitrates) only if beta-blockers alone are insufficient—never use vasodilators without prior beta-blockade as this causes reflex tachycardia and increases aortic wall stress 1, 2
• Provide adequate pain control with morphine sulfate to reduce sympathetic stimulation and achieve hemodynamic targets 1, 2
• Transfer immediately to intensive care unit with invasive arterial line monitoring and continuous three-lead ECG recording 1, 2
• Transfer to high-volume aortic center with multidisciplinary team if this can be accomplished without significant surgical delay 1

Surgical Approach and Timing

Emergency surgical consultation and immediate surgical intervention is mandatory for all Type A dissections, regardless of age or comorbidities 1:

• Surgery reduces 1-month mortality from 90% to 30% compared to medical management alone 1
• Acute Type A dissection has 50% mortality within 48 hours without surgery 1
• Even in octogenarians, surgical mortality (37.9%) is lower than medical management (55.2%) 1
• Age alone should not exclude patients from surgery 1

Special Consideration for Neurological Complications

Patients presenting with cerebral malperfusion or non-hemorrhagic stroke should still undergo immediate aortic surgery to improve neurological outcome and reduce mortality 1:

• Surgical repair can be performed safely even with preoperative stroke, with operative mortality of 7% versus 100% mortality without surgery 3
• 80% of patients operated within 10 hours of stroke onset show neurological improvement 3
• No worsening of neurological status occurs after surgical repair 3

Malperfusion Syndromes

All patients with Type A dissection presenting with any malperfusion (cerebral, mesenteric, lower limb, or renal) require immediate aortic surgery 1:

• For clinically significant mesenteric malperfusion, consider immediate invasive angiographic diagnostics to evaluate percutaneous repair before or directly after aortic surgery in centers with expertise 1
• Coronary malperfusion requires concomitant coronary artery bypass grafting with aortic repair 4

Surgical Technique Selection

The extent of repair depends on specific anatomical features:

Aortic Root Management

For patients with normal-sized aortic root and no valve pathology:

• Aortic valve resuspension is recommended over valve replacement 1
• Tubular graft anastomosed to sinotubular ridge with valve preservation 1, 5

For patients with extensive aortic root destruction, root aneurysm, or known genetic aortic disorder (e.g., Marfan syndrome):

• Aortic root replacement with mechanical or biological valved conduit (composite graft) is mandatory 1

Valve-sparing root repair may be considered only in selected patients when performed by experienced surgeons 1, 5

Distal Repair Strategy

Open distal anastomosis is recommended to improve survival and increase false lumen thrombosis rates 1

For patients without intimal tear in the arch or significant arch aneurysm:

• Hemi-arch repair is recommended over more extensive arch replacement 1

For patients with secondary intimal tear in the arch or proximal descending thoracic aorta:

• Extended aortic repair with stenting of proximal descending thoracic aorta (frozen elephant trunk technique) may be considered to reduce late distal aortic complications 1
• This approach is particularly beneficial for patients with visceral or renal malperfusion where the primary entry tear is in the descending aorta 1

Post-operative Medical Management

After 24 hours of hemodynamic stability with preserved gastrointestinal transit:

• Switch from intravenous to oral beta-blockers with up-titration of other blood pressure-lowering agents as necessary 1, 2
• If beta-blockers are contraindicated, use non-dihydropyridine calcium channel blockers 1

Long-term management:

• Target blood pressure <135/80 mmHg 2
• Lifelong beta-blocker therapy is mandatory for patients with hereditary diseases such as Marfan syndrome 2
• Regular imaging follow-up (CT or MRI) to monitor for false lumen expansion or aneurysm formation 2

Critical Pitfalls to Avoid

• Never delay surgery for diagnostic workup beyond what is necessary—time is mortality 1
• Never use vasodilators without prior beta-blockade—this increases aortic wall stress through reflex tachycardia 2
• Never exclude elderly patients from surgery based on age alone—outcomes are superior to medical management even in octogenarians 1
• Never assume neurological deficits are a contraindication to surgery—immediate repair improves neurological outcomes 1, 3
• Be aware that reoperation rates are approximately 10% at 5 years and up to 40% at 10 years, requiring lifelong surveillance 2