Management of Aortic Dissection

Immediate Medical Management

• The American Heart Association recommends immediate intravenous beta-blocker therapy to achieve a target heart rate ≤60 beats per minute and systolic blood pressure of 100-120 mmHg in patients with suspected or confirmed aortic dissection 1, 2, 3
• The American College of Cardiology suggests initiating intravenous beta-blockers immediately as first-line therapy to reduce aortic wall shear stress and prevent dissection propagation 1, 2
• The target heart rate should be ≤60 beats per minute before addressing blood pressure, according to the American Heart Association 1, 3
• Once heart rate is controlled, if systolic blood pressure remains >120 mmHg, the European Society of Cardiology recommends adding vasodilators to achieve target systolic blood pressure of 100-120 mmHg 1, 3

Surgical Referral: When to Refer

• The American Heart Association recommends urgent surgical consultation for all patients with thoracic aortic dissection regardless of anatomic location as soon as the diagnosis is made or highly suspected 1
• The European Society of Cardiology suggests that type A dissection requires emergent surgical repair due to extremely high risk of rupture, tamponade, and death 1, 2, 4, 3
• Surgery aims to prevent aortic rupture, pericardial tamponade, and relieve aortic regurgitation, according to the European Heart Journal 5, 4
• The American College of Cardiology recommends not delaying surgery for extensive imaging in hemodynamically unstable patients 3

Management of Malperfusion

• The European Society of Cardiology recommends immediate aortic surgery for type A dissection with malperfusion (cerebral, mesenteric, lower limb, or renal) 2
• For cerebral malperfusion or non-hemorrhagic stroke, the European Heart Journal suggests considering immediate aortic surgery to improve neurological outcomes and reduce mortality 2

Chronic Dissection Management

• The European Society of Cardiology recommends treatment when descending thoracic aortic diameter reaches ≥60 mm in patients at reasonable surgical risk 2
• Intervention should be considered at ≥55 mm diameter in patients with low procedural risk, according to the European Heart Journal 2

Long-Term Management and Follow-Up

• The European Society of Cardiology suggests switching from intravenous to oral beta-blockers after 24 hours of hemodynamic stability if gastrointestinal function is preserved 2, 3
• The American College of Cardiology recommends target long-term blood pressure <135/80 mmHg 3
• The European Heart Journal suggests performing follow-up imaging with CT and transthoracic echocardiography within 6 months, then at 12 months, and yearly if stable 3
• MRI is the preferred technique for long-term surveillance, according to the European Heart Journal 6

Critical Pitfalls to Avoid

• The American Heart Association recommends never performing pericardiocentesis before surgery in tamponade cases, as reducing intrapericardial pressure causes recurrent bleeding 3
• If initial imaging is negative but clinical suspicion remains high, the American College of Cardiology suggests obtaining a second imaging study 1

Immediate Management and Intervention Criteria for Infrarenal (Type B) Aortic Dissection

Emergency Activation and Team Notification

• Activate EMS to transport the patient with lights and sirens when the patient is located and symptomatic, as recommended by the European Society of Cardiology (ESC). [@1]
• Notify the on‑call vascular‑surgery team of the CT findings before the patient arrives, per ESC guidance. [@2, @3, @1]

High‑Risk Imaging Features Guiding Urgency

• Fluid extravasation into the pericardium, pleural space, or mediastinum indicates a contained or impending rupture with mortality rates of ~54 % at 6 h and ~76 % at 24 h (ESC). [@4, @1]
• Periaortic hematoma signals a contained rupture that requires urgent treatment (ESC). [@2, @1]
• Maximum aortic diameter ≥ 50 mm predicts complications and is an indication for closer monitoring or intervention (ESC). [@3]
• Progressive aortic wall thickness > 11 mm or an enlarging aortic diameter is a high‑risk sign (ESC). [@3]
• Branch‑vessel compromise (renal, mesenteric, iliac) can cause multiorgan failure, a major cause of death after dissection (ESC). [@4]
• Increasing pleural or peritoneal effusions identify patients at the highest risk of rupture (ESC). [@2, @1]

Criteria for Urgent Endovascular or Surgical Intervention

• Recurrent or refractory pain despite aggressive medical therapy (ESC). [@3]
• Inability to achieve target systolic blood pressure ≤ 120 mmHg despite maximal medical treatment (ESC). [@3]
• Progressive enlargement of the aortic diameter or a diameter ≥ 50 mm (ESC). [@3]
• Recurrent or increasing pleural effusion (ESC). [@3]
• Evidence of organ ischemia (bowel, kidney, lower extremity) from branch‑vessel compromise (ESC). [@4, @3]
• Periaortic hematoma indicating contained rupture (ESC). [@2, @1]
• Intimal disruption with contrast enhancement on CT imaging (ESC). [@3]

Standard Medical Management for Uncomplicated Type B Dissection

• Initial anti‑impulse therapy (beta‑blockade followed by controlled vasodilation) is the standard approach for uncomplicated infrarenal dissection (ESC). [@3]
• Serial imaging (CT or MRI) is required to monitor for the development of complications (ESC). [@3]
• Thoracic endovascular aortic repair (TEVAR) is recommended for complicated cases, showing a 30‑day mortality of 17‑19 % versus 25‑33 % for open surgery (ESC). [@2, @1]

Documentation and Quality Assurance

• Prompt review of imaging is essential; delays increase mortality (ESC). [@2, @3, @1]
• Document CT findings and the presence or absence of high‑risk features in the medical record (ESC). [@2, @3, @1]