Acute Aortic Dissection Management

Introduction and Diagnosis

The European Society of Cardiology recommends CT scan from neck to pelvis as the primary diagnostic tool for suspected acute aortic syndrome, providing critical information about entry tear location, dissection extent, and complications 1
If initial imaging is negative but clinical suspicion remains high, a second imaging study should be obtained, as suggested by the American Heart Association 2
Transesophageal echocardiography (TOE) is valuable for perioperative management and detecting complications, according to the European Heart Journal 1
Aortic dissection is frequently misdiagnosed initially, with a high index of suspicion necessary, especially in patients with unexplained chest/back/abdominal pain, pulse deficits, or neurological symptoms, as emphasized by the American Heart Association 2

All Type A aortic dissections require emergency surgical repair due to 50% mortality within the first 48 hours if not operated, high risk of aortic rupture, pericardial tamponade, and aortic regurgitation 3
The European Society of Cardiology recommends immediate surgical intervention for all patients with Type A aortic dissection, as surgery reduces 1-month mortality from 90% to 30% compared to medical management 3
The European Society of Cardiology notes that even patients with unfavorable presentations (coma, shock, malperfusion, stroke) benefit from surgery over medical management 3
Immediate surgical consultation is mandatory for all aortic dissections, with emergency surgical repair indicated for all Type A dissections due to high risk of life-threatening complications 1, 2

Control of pain and hemodynamic state is crucial while preparing for surgery, according to the European Heart Journal 3
The American College of Cardiology recommends target heart rate ≤60 bpm and systolic BP <120 mmHg, with heart rate control preceding vasodilator therapy to prevent reflex tachycardia 1, 2
The European Society of Cardiology recommends IV beta-blockers (Class I recommendation) titrated to target heart rate ≤60 bpm, with labetalol offering the advantage of combined alpha and beta blockade from a single agent 1, 2
For beta-blocker contraindications, non-dihydropyridine calcium channel blockers should be used, as suggested by the European Heart Journal 1
If SBP remains >120 mmHg after adequate heart rate control, add ACE inhibitors or other vasodilators, with caution to never initiate vasodilators before rate control due to risk of reflex tachycardia 2
Never initiate vasodilators before heart rate control, and use beta-blockers cautiously with acute aortic regurgitation, as recommended by the American Heart Association 2

Transfer to high-volume aortic centers with multidisciplinary teams should be considered if transfer won't significantly delay surgery, as recommended by the European Heart Journal 1
The European Society of Cardiology suggests that for normal valve and root, supracommissural graft implantation is a suitable approach 4
For detached commissures, valve resuspension is recommended by the European Society of Cardiology 4
For extensive root destruction, root aneurysm, or genetic disorders, aortic root replacement with mechanical or biological valved conduit is recommended 1
For partially dissected root without valve pathology, aortic valve resuspension is recommended, with valve-sparing root repair considered when performed by experienced surgeons 1
Open distal anastomosis is recommended to improve survival and increase false lumen thrombosis, with hemi-arch repair preferred when no intimal tear or significant aneurysm involves the arch 1
Extended repair with proximal descending thoracic aorta stenting may be considered with secondary tears in arch or proximal descending aorta 1
High-risk patients, including the elderly, should not be excluded from surgical treatment based on age alone, though mortality is higher 3

Intervention for malperfusion, progression, aneurysm formation, or uncontrollable pain/hypertension is recommended, with consideration of TEVAR in subacute phase (14-90 days) for uncomplicated Type B with high-risk features 1, 2
For chronic Type B dissection, intervention is recommended for descending thoracic aortic diameter ≥60 mm (or ≥55 mm in low-risk patients) 1

Perioperative mortality rates for Type A dissection range from 15-25% despite improvements in surgical techniques 3
Long-term survival rates after successful surgery are significant, with 5-year survival of 71% and 10-year survival of 54% 3
Imaging at 1, 3, 6, and 12 months after onset, then yearly if stable, is recommended for medically treated Type B dissection 1
After surgical repair, follow-up imaging within 6 months, then at 12 months and yearly thereafter is recommended 1
If no complications occur within 5 years, imaging every 2 years may be considered 1