Management of Aortic Dissection
Immediate Medical Stabilization (All Patients)
All patients with aortic dissection require immediate transfer to an intensive care unit with invasive arterial blood pressure monitoring and aggressive medical therapy to reduce aortic wall stress, regardless of dissection type. 1, 2
Administer intravenous beta-blockers as first-line therapy targeting systolic blood pressure 100-120 mmHg and heart rate ≤60 beats per minute 1, 3, 2
Add sodium nitroprusside for additional blood pressure control only after beta-blockade is established if target blood pressure is not achieved with beta-blockers alone 1, 3, 2
For patients with obstructive pulmonary disease who cannot tolerate beta-blockers, use calcium channel blockers for blood pressure control 1
Place arterial line in the right radial artery for continuous invasive monitoring (use left radial if brachiocephalic trunk involvement is suspected) 1, 2
Type A Dissection (Ascending Aorta): Emergency Surgery
Emergency surgical intervention is mandatory for all acute Type A aortic dissections to prevent aortic rupture, pericardial tamponade, and death. 1, 2, 4, 5
Surgical Approach
Immediate aortic surgery is recommended for Type A dissection with or without malperfusion complications (cerebral, mesenteric, renal, or lower limb) (Class I, Level B) 1
Direct admission to hybrid operating room with onsite aortic team for immediate surgery 1
Perform ascending aortic repair with consideration for aortic arch replacement or frozen elephant trunk technique based on extension of dissection 1, 3
Use moderate to deep hypothermia with circulatory arrest for arch reconstruction 3
Fortify dissected aortic layers using gelatin resorcinol formaldehyde glue or Teflon felt strips 3
Management of Malperfusion in Type A Dissection
For cerebral malperfusion or non-hemorrhagic stroke: proceed immediately to aortic surgery to improve neurological outcome and reduce mortality (Class IIa, Level B) 1
For clinically significant mesenteric malperfusion: consider immediate invasive angiographic diagnostics to evaluate percutaneous malperfusion repair before or directly after aortic surgery in centers with expertise (Class IIa, Level C) 1
If malperfusion persists after aortic surgery, perform angiographic control and/or percutaneous malperfusion repair or TEVAR/EVAR (Class IIa) 1
Critical Pitfalls to Avoid
Never perform pericardiocentesis before surgery in tamponade cases, as reducing intrapericardial pressure causes recurrent bleeding 3
Never delay surgery for extensive imaging in hemodynamically unstable patients; transesophageal echocardiography can be performed as the sole diagnostic procedure in the operating room 3, 2
Type B Dissection (Descending Aorta): Risk-Stratified Approach
Complicated Acute Type B Dissection
Emergency endovascular intervention (TEVAR) is recommended as first-line therapy for complicated acute Type B dissection (Class I, Level B) 1, 6
Complicated features requiring emergency intervention include: 1
- Aortic rupture or impending rupture
- Malperfusion syndrome (cerebral, mesenteric, renal, or limb)
- Refractory hypertension despite maximal medical therapy
- Persistent or recurrent pain despite aggressive blood pressure control
- Rapid aortic expansion
Uncomplicated Acute Type B Dissection
Medical therapy including pain relief and blood pressure control is recommended in all patients with acute Type B dissection (Class I, Level B) 1
Beta-blockers should be considered as first-line medical therapy (Class IIa, Level B) 1
In selected patients with high-risk features and suitable anatomy, TEVAR in the subacute phase (between 14 and 90 days) should be considered to improve late outcomes and promote aortic remodeling (Class IIa, Level B) 1, 2
High-risk features indicating consideration for pre-emptive TEVAR include: 2
- Primary entry tear >10 mm at inner aortic curvature
- Initial aortic diameter >40 mm
- False lumen diameter >20 mm
- Multiple fenestrations
- Partial false lumen thrombosis
Retrograde Type A Extension
- If retrograde aortic dissection into the ascending aorta occurs, immediate aortic surgery is required (ascending aorta, aortic arch, or frozen elephant trunk based on extension) (Class I) 1
Chronic Dissection Management
Medical Management
Antihypertensive therapy is recommended in all patients with chronic Type B dissection (Class I, Level B) 1, 7
Target long-term blood pressure <135/80 mmHg (systolic <130 mmHg during exercise) 3, 2, 7
Beta-blockers are the preferred first-line antihypertensive agents 7
Most patients require combination therapy with multiple antihypertensive agents to achieve target blood pressure 7
Never use vasodilators without prior beta-blockade due to reflex tachycardia that increases aortic wall stress 2, 7
Surgical Indications for Chronic Type B Dissection
In chronic Type B dissection with a descending thoracic aortic diameter ≥60 mm, treatment is recommended in patients at reasonable surgical risk (Class I, Level B) 1, 7
For diameter ≥55 mm, intervention should be considered in patients with low procedural risk (Class IIa, Level C) 1
Emergency intervention is recommended for acute symptoms of malperfusion, rupture, or progression of disease (Class I, Level C) 1
Fenestrated/branched stent grafts may be considered for chronic post-dissection thoracoabdominal aortic aneurysms when treatment is indicated (Class IIb, Level C) 1
Post-Operative and Long-Term Management
Transition to Oral Therapy
- Switch from intravenous to oral beta-blockers after 24 hours of hemodynamic stability if gastrointestinal function is preserved 3, 2
Surveillance Imaging
MRI is the preferred modality for serial follow-up as it avoids ionizing radiation and nephrotoxic contrast while providing excellent aortic visualization 2, 7
For medically managed chronic Type B dissection, obtain imaging at 1,3,6, and 12 months after diagnosis, then yearly if stable 7
CT angiography is an acceptable alternative, particularly in patients over 60 years where radiation exposure is less concerning 7
Perform follow-up imaging with CT and transthoracic echocardiography within 6 months, then at 12 months, and yearly if stable 3
Long-Term Outcomes
Reoperation rate is approximately 10% at 5 years and up to 40% at 10 years after primary surgery 3
Majority of late deaths after surgery are due to aortic rupture, making timely detection of complications critical 7
Patients must be followed by physicians with expertise in aortic dissection who can recognize subtle signs of disease progression 7
Special Considerations
Pregnancy
Management requires a multidisciplinary team in specialized centers 1
Use drugs with lowest teratogenic impact for medical management 1
For Type A dissection with viable fetus: perform cesarean delivery before aortic repair 1
For Type A dissection with non-viable fetus: perform surgery with fetus in place 1
For Type B dissection, strict medical management is recommended, though successful TEVAR has been described in selected complicated cases 1
Connective Tissue Disorders
Patients with known or suspected heritable thoracic aortic disease require specialized consideration and may have different thresholds for intervention 1
Genetic disorders of connective tissue (especially Marfan syndrome) promote degeneration of the aortic media and increase risk 5, 8
Critical Clinical Pitfalls
Mortality is 1-2% per hour in untreated Type A dissection, emphasizing the need for rapid diagnosis and treatment 2
Never use dihydropyridine calcium channel blockers without beta-blockers due to reflex tachycardia risk 3, 2
Avoid chest X-ray in unstable patients as it delays treatment, despite being abnormal in 60-90% of cases 1, 2
Repeat sternotomy requires extreme caution as the aorta is usually unprotected by pericardium in reoperation cases 3