Mortality Risk and Management of Ruptured Acute Type B Aortic Dissection
Ruptured acute type B aortic dissection carries an extremely high mortality risk and requires emergent thoracic endovascular aortic repair (TEVAR) as the intervention of choice.
Mortality Risk
Rupture is the major cause of early death in acute aortic syndrome and represents a catastrophic complication with extremely poor survival. 1
Rupture is a significant independent predictor of poor survival in type B dissection, with patients experiencing rupture, shock, or malperfusion having actuarial survival of only 62% at 1 year and 40% at 5 years. 2
The presence of rupture (P=0.0001) emerged as one of the most significant predictors of mortality in acute type B dissection, along with shock and malperfusion syndrome. 2
For acute complicated type B dissection (which includes rupture), if left untreated, there is a high risk of death from aortic rupture or irreversible organ damage. 3
Overall acute mortality for type B dissection requiring surgery is approximately 22%, though this includes all surgical indications, not rupture alone. 2
Emergent Intervention Recommended
Acute type B aortic dissection with rupture is classified as "complicated" and requires emergent TEVAR. 4
Primary Treatment Approach
Thoracic endovascular aortic repair (TEVAR) is the treatment of choice for acute complicated type B aortic dissection, including rupture, as it has become the preferred treatment due to superior outcomes compared to open repair and medical therapy alone. 3, 4
TEVAR should be performed emergently when rupture is present, as this represents a life-threatening complication requiring immediate intervention. 4
The Valiant Captivia Thoracic Stent Graft System demonstrated freedom from all-cause mortality of 79.1% and dissection-related mortality of 90.0% at 3 years in acute complicated type B dissection. 3
Concurrent Medical Management
Immediate anti-impulse medical therapy must be initiated regardless of whether intervention is performed, focusing on strict blood pressure control and pain management. 1, 4
Medical therapy to control pain and hemodynamic state is essential in all cases. 1
Open Surgical Repair
Open surgical repair is seldom required and reserved only for select cases where TEVAR is not feasible or has failed. 4
Historical data on open surgery for acute type B dissection showed 0% hospital mortality in highly selected patients, but with 47% experiencing important complications including respiratory failure (10 patients), infectious complications (6), dialysis requirement (4), and paraplegia (1 patient). 5
Critical Prognostic Factors
Additional high-risk features that compound mortality risk include: 2
- Shock (P=0.0001) - independent risk factor for mortality
- Malperfusion syndrome (P=0.001)
- Pleural effusion (P=0.003)
- Age (P=0.003)
- Aortic diameter >4.5 cm (P=0.002)
Common Pitfalls
Delay in diagnosis significantly worsens outcomes - only 15% of cases were diagnosed before death in historical studies, emphasizing the need for rapid imaging and intervention. 6
Do not attempt medical management alone in the presence of rupture - this is an absolute indication for emergent intervention. 4
Patients with rupture presenting in shock have particularly poor prognosis and require immediate transfer to a center capable of performing emergent TEVAR. 2