How should a patient with aortic dissection be managed?

Management of Aortic Dissection

All patients with Type A aortic dissection require immediate emergency surgical repair, while Type B dissection should be managed medically unless life-threatening complications develop. 1

Immediate Stabilization and Medical Management

Blood Pressure and Heart Rate Control

Initiate intravenous beta-blockers immediately as first-line therapy, targeting systolic blood pressure <120 mmHg and heart rate ≤60 beats per minute. 1, 2, 3

• Esmolol is preferred due to its short half-life: administer 0.5 mg/kg loading dose over 2-5 minutes, followed by infusion of 0.10-0.20 mg/kg/min (maximum 0.3 mg/kg/min). 3
• Alternative beta-blockers include propranolol, metoprolol, or labetalol (which has both alpha- and beta-blocking properties). 2, 4
• If beta-blockers are contraindicated, use non-dihydropyridine calcium channel blockers (verapamil or diltiazem) for rate control. 1, 2, 3
• After achieving heart rate control, if systolic blood pressure remains >120 mmHg, add vasodilators such as sodium nitroprusside or ACE inhibitors. 1, 2

Critical Pitfall to Avoid

Never initiate vasodilator therapy before achieving rate control, as this causes reflex tachycardia that increases aortic wall stress and can propagate the dissection. 1, 3

Monitoring and Supportive Care

• Transfer to intensive care unit with invasive arterial line monitoring for accurate blood pressure management. 2, 4
• Provide adequate pain control with morphine sulfate to reduce sympathetic stimulation. 2, 4
• Establish continuous three-lead ECG monitoring. 2
• Use beta-blockers cautiously in acute aortic regurgitation, as they block compensatory tachycardia. 1

Diagnostic Imaging

Obtain CT angiography from neck to pelvis immediately as first-line imaging, as it is widely available, accurate, and provides critical information about entry tear location, dissection extent, and complications including malperfusion, dilatation, or rupture. 3

• If high clinical suspicion exists but initial imaging is negative, obtain a second imaging study. 1
• For profoundly unstable patients who cannot be transported, perform bedside transthoracic echocardiography to identify cardiac tamponade or other immediate life-threatening complications. 4, 5
• Transesophageal echocardiography is recommended to guide peri-operative management and detect complications, particularly in unstable patients. 3, 5

Type A Dissection Management

Obtain urgent surgical consultation immediately for all patients with Type A dissection, as mortality is 1-2% per hour if untreated. 1, 3, 6

Surgical Approach

• Perform open distal anastomosis to improve survival and increase false lumen thrombosis rates. 1, 3
• In patients with partially dissected aortic root but no significant valve leaflet pathology, perform aortic valve resuspension rather than valve replacement. 1
• For patients without intimal tear in the arch or significant arch aneurysm, perform hemi-arch repair rather than more extensive arch replacement. 1
• Consider extended aortic repair with stenting of proximal descending thoracic aorta (frozen elephant trunk technique) if secondary intimal tear exists in the arch or proximal descending aorta to reduce late distal aortic complications. 1, 3
• Valve-sparing root repair may be considered when performed by experienced surgeons. 1

Malperfusion Management

In patients presenting with malperfusion (cerebral, mesenteric, lower limb, or renal), perform immediate aortic surgery. 1

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

Critical Pitfall to Avoid

Never perform pericardiocentesis before surgery in patients with cardiac tamponade from Type A dissection, as reducing intrapericardial pressure may cause recurrent bleeding. 3

Type B Dissection Management

Manage uncomplicated Type B dissection medically with aggressive blood pressure and heart rate control. 1, 3, 4

Indications for Emergency Intervention

Perform emergency intervention (preferably TEVAR) for complicated Type B dissection presenting with: 1, 2, 3

• Aortic rupture or impending rupture
• Malperfusion syndrome
• Intractable or refractory pain
• Rapidly expanding aortic diameter
• Periaortic or mediastinal hematoma
• Uncontrollable hypertension despite medical therapy
• Dissection occurring in a previously aneurysmal aorta

Subacute Management

• In uncomplicated acute 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 aortic complications. 1

Chronic Dissection Management

Type B Chronic Dissection

• With descending thoracic aortic diameter ≥60 mm, treatment is recommended in patients at reasonable surgical risk. 1
• With descending thoracic aortic diameter ≥55 mm, intervention should be considered in patients with low procedural risk. 1
• For chronic post-dissection thoracoabdominal aortic aneurysms, fenestrated/branched stent grafts may be considered when treatment is indicated. 1

Long-Term Management and Follow-Up

Transition to Oral Therapy

After 24 hours of hemodynamic stability with intravenous therapy, switch to oral beta-blockers if gastrointestinal transit is preserved. 2, 4

• Target long-term blood pressure <135/80 mmHg with beta-blockers as preferred agents, often requiring combination therapy. 2

Imaging Surveillance Protocol

For medically treated Type B dissection or intramural hematoma, perform imaging at 1,3,6, and 12 months after onset, then yearly if findings remain stable. 1, 2, 3

• After open surgery for acute aortic syndrome, perform CT and transthoracic echocardiography within 6 months, then CT at 12 months and yearly if findings are stable. 1
• If no complications occur within the first 5 years, perform CT every 2 years thereafter. 1
• MRI is preferred for long-term follow-up to avoid radiation and nephrotoxic contrast, though CT is acceptable particularly in patients >60 years. 2, 3

Special Populations

Hereditary Connective Tissue Disorders

Lifelong beta-adrenergic blockade is mandatory for patients with Marfan syndrome, Loeys-Dietz syndrome, or Ehlers-Danlos syndrome to prevent dissection. 2, 3, 4, 6

Pregnant Patients

Management requires a multidisciplinary team at specialized centers, using drugs with the lowest teratogenic impact. 2, 4

Transfer Considerations

Transfer from a low- to a high-volume aortic center with a multidisciplinary team should be considered to improve survival if transfer can be accomplished without significant delay in surgery. 1