Aortic Dissection Management

Initial Assessment and Management

The European Society of Cardiology recommends immediate transfer to an intensive care unit with invasive blood pressure monitoring via arterial line and continuous ECG recording for patients with aortic dissection 3
Pain control with morphine sulfate is recommended to reduce sympathetic stimulation in patients with aortic dissection 3
Urgent diagnostic imaging with CT angiography, transesophageal echocardiography (TEE), or MRI is recommended depending on institutional capabilities and patient stability 3
Target systolic blood pressure between 100-120 mmHg and heart rate ≤60 beats per minute to reduce shear stress on the aortic wall 3, 4
Administer intravenous beta-blockers as first-line therapy (propranolol, esmolol, or labetalol) for patients with aortic dissection 3, 2
If beta-blockers alone are insufficient, add vasodilators such as sodium nitroprusside (never use vasodilators without prior beta-blockade) for patients with aortic dissection 3, 4

Emergency surgical intervention is required to prevent aortic rupture, pericardial tamponade, and relieve aortic regurgitation in patients with Type A dissection 5, 1
Surgical options include supracommisural graft implantation, valve resuspension, composite graft implantation, and subtotal or total arch replacement for patients with Type A dissection 5, 6, 7, 8
The European Heart Society recommends surgical intervention for Type A dissections to prevent complications 1

Uncomplicated Type B dissections are managed medically with aggressive blood pressure and heart rate control, according to the European Society of Cardiology 1, 2
Surgical or endovascular intervention is indicated for complicated Type B dissections with persistent or recurrent pain, early expansion of the aortic diameter, peripheral ischemic complications, rupture, or signs of impending rupture 5, 9
Thoracic endovascular aortic repair (TEVAR) aims to stabilize the dissected aorta by covering the primary entry tear, redirecting blood flow to the true lumen in patients with Type B dissection 1

Standard approach to the ascending aorta and transverse aortic arch is through median sternotomy, as recommended by the European Heart Society 8
For descending aorta dissections, a posterolateral chest incision is commonly used 6
Most surgeons perform the operation using extracorporeal circulation via left heart bypass 6
Moderate hypothermia with equalized perfusion pressures during graft implantation is recommended 6
Dissected layers are conjoined using teflon felt strips or gelatin resorcinol formaldehyde glue (GRF-glue) 7

Transition from intravenous to oral beta-blockers after 24 hours of hemodynamic stability is recommended for patients with aortic dissection 3, 2
Target long-term blood pressure <135/80 mmHg for patients with aortic dissection 3, 4
Regular imaging follow-up to monitor for complications such as false lumen expansion or aneurysm formation is recommended for patients with aortic dissection 3, 2
Consider reoperation when the dissected aorta becomes aneurysmatic (5-6 cm in diameter) 2
Lifelong beta-blocker therapy is recommended for patients with hereditary diseases such as Marfan syndrome 3, 2

Avoid using vasodilators alone without prior beta-blockade as this can increase aortic wall stress through reflex tachycardia 4
Avoid dihydropyridine calcium channel blockers without beta-blockers due to risk of reflex tachycardia 4
The rate of reoperation for Type A dissection is approximately 10% at 5 years and up to 40% at 10 years after primary surgery, according to the European Society of Cardiology 2