Aortic dissection

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

INITIAL

hemodynamically unstable: suspected aortic dissection

1st line – advanced life support with hemodynamic support

ACUTE

confirmed aortic dissection

1st line – beta-blocker or nondihydropyridine calcium-channel blocker

Back

1st line –

beta-blocker or nondihydropyridine calcium-channel blocker

Initial management of both type A and B dissections involves anti-impulse medical therapy, regardless of definitive treatment.[4][10][13]

Intravenous beta-blockers are used to achieve a systolic blood pressure less than 120 mmHg or to lowest blood pressure that maintains adequate end-organ perfusion and an appropriate target heart rate.[4][10]

Recommendations for target heart rate vary; the American College of Cardiology/American Heart Association recommend a target heart rate of 60 to 80 bpm; the Society of Thoracic Surgeons/American Association for Thoracic Surgery recommend maintaining a heart rate of <70 bpm; the European Society of Cardiology recommends a heart rate of <60 bpm as the target for medical therapy.[4][6][10][13]

In patients with contraindications (e.g., acute aortic regurgitation, heart block, or bradycardia), or intolerance to beta-blockers, initial management with an intravenous nondihydropyridine calcium-channel blocker (e.g., diltiazem) is reasonable for heart rate control.[4] Invasive monitoring of blood pressure with an arterial line in an intensive care unit setting is recommended to monitor the anti-impulse therapy to ultimately decrease aortic wall stress.[4][10]

Primary options

labetalol: 20 mg intravenously initially, followed by 20-80 mg every 10 minutes (or 0.5 to 10 mg/minute infusion) until target heart rate and blood pressure are reached, maximum 300 mg/total dose

esmolol: 500 micrograms/kg intravenously initially, followed by 25-50 micrograms/kg/minute infusion, titrate infusion by 25-50 micrograms/kg/minute every 5 minutes until target heart rate and blood pressure are reached (may consider repeat loading dose before every up titration), maximum 300 micrograms/kg/minute

metoprolol tartrate: 2.5 to 5 mg intravenously every 5-10 minutes when required, maximum 15 mg/total dose

Secondary options

diltiazem: 0.25 mg/kg intravenously initially (may give another dose of 0.35 mg/kg after 15 minutes), followed by 5-15 mg/hour infusion for <24 hours

Plus – opioid analgesia

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Plus –

opioid analgesia

Treatment recommended for ALL patients in selected patient group

Pain control is an important first-line therapy to reduce sympathetic tone and facilitate hemodynamic stability.[4][10][13] It should be noted that morphine causes vasodilation and reduces the heart rate by increasing vagal tone.

Primary options

morphine sulfate: 2.5 to 10 mg intravenously every 2-6 hours when required, adjust dose according to response

hydromorphone: 0.2 to 1 mg intravenously every 2-3 hours when required, adjust dose according to response

fentanyl: 50-100 micrograms intravenously every 1-2 hours when required

Consider – vasodilator

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Consider –

vasodilator

Treatment recommended for SOME patients in selected patient group

If first-line treatment with beta-blockers (or nondihydropyridine calcium-channel blockers in patients with contraindications or intolerance to beta-blockers) and analgesia fail to achieve a systolic blood pressure less than 120 mmHg and an appropriate target heart rate, then intravenous antihypertensive vasodilator therapy (such as nitroprusside) should be added.[4][13]

Vasodilators should be used with caution and avoided as initial treatment, ensuring chronotropic control with beta-blockers is established first, to avoid reflex tachycardia.[4]

Primary options

nitroprusside: 0.3 to 0.5 micrograms/kg/minute intravenously initially, increase by 0.5 micrograms/kg/minute increments every 5 minutes, maximum 10 micrograms/kg/minute for 10 minutes

type A

Plus – open surgery or endovascular stent-graft repair

Back

Plus –

open surgery or endovascular stent-graft repair

Treatment recommended for ALL patients in selected patient group

Type A dissection involves the ascending aorta with or without involvement of the arch and descending aorta. In patients presenting with suspected or confirmed acute type A aortic dissection, there is a high risk of associated life-threatening complications.[4] Emergency surgical evaluation and intervention is recommended. The mortality rate of medical management alone for acute type A aortic dissection is two to three times that of surgical intervention.[37] In a patient stable enough for transfer, moving to a high-volume aortic center is recommended in order to improve survival.[4]

Depending on the extent of retrograde extension, the aortic valve may or may not need to be repaired or replaced.[10] This is to prevent cardiac tamponade or fatal exsanguination from aortic rupture.

Therapeutic options include: open aortic arch replacement; transposition of supra-aortic branches with subsequent endovascular repair; total endovascular repair; or the frozen elephant trunk repair technique, which combines open repair of the proximal aorta under deep hypothermic circulatory arrest, together with placement of thoracic stent grafts into the distal aortic arch and upper descending thoracic aorta.[38]

In patients with renal, mesenteric, or lower extremity malperfusion, immediate operative repair of the ascending aorta is recommended.[4] In patients presenting with clinically significant mesenteric (e.g., celiac, superior mesenteric) malperfusion, immediate mesenteric revascularization via endovascular or open surgical intervention before ascending aortic repair is also reasonable.[4] Evidence of mesenteric malperfusion includes abdominal pain, bowel ischemia, lactic acidosis, or elevation of liver function test results.[4]

One meta-analysis of comparator observational studies reported lower stroke and mortality rates, but higher spinal cord ischemia events, with the frozen elephant trunk technique compared with conventional aortic arch surgery.[42] Longer term follow-up is necessary.[43]

type B with complications (rupture, visceral/extremity ischemia, expansion, or persistent pain)

Plus – endovascular stent-graft repair or open surgery

Back

Plus –

endovascular stent-graft repair or open surgery

Treatment recommended for ALL patients in selected patient group

Type B dissection involves only the descending thoracic aorta (distal to the left subclavian artery) and/or abdominal aorta.

Urgent surgical or endovascular intervention is required if type B dissection is complicated by rupture, visceral or extremity ischemia, aneurysmal expansion, or persistent pain.[4]

American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend endovascular stent grafting rather than open surgical repair in patients with acute type B aortic dissection with rupture, in the presence of suitable anatomy.[4] The ACC/AHA note that an endovascular approach, rather than open surgical repair, is also reasonable in patients with other complications (e.g., branch artery occlusion and malperfusion, extension of dissection, aortic enlargement, intractable pain, or uncontrolled hypertension).[4] The Society of Thoracic Surgeons/American Association for Thoracic Surgery state that thoracic endovascular aortic repair (TEVAR) is indicated in patients with complicated hyperacute, acute, or subacute type B dissection and favorable anatomy for TEVAR.[6] However, open surgical repair is reasonable over TEVAR as a more durable treatment in patients with connective tissue disorders who have type B dissection with progression of disease despite optimal medical therapy.[6]

The European Society of Cardiology recommends endovascular therapy for complicated acute type B dissection as the first-line treatment, if there is favorable anatomy, and reserves open surgical repair for patients unsuitable for endovascular therapy.[10]

For complicated type B dissections, the goal of open surgery is to resect/cover the entry tear and re-establish flow into compromised branch vessels.

type B uncomplicated

Plus – consider endovascular stent-graft repair

Back

Plus –

consider endovascular stent-graft repair

Treatment recommended for ALL patients in selected patient group

Patients with uncomplicated type B aortic dissection (i.e., without end-organ malperfusion) are usually managed medically with blood pressure and pain control during the acute phase (less than 14 days).[10][13][23][38] The American College of Cardiology/American Heart Association and the Society of Thoracic Surgeons/American Association for Thoracic Surgery state that optimal medical therapy remains the recommended treatment for patients with uncomplicated type B dissection.[6]

Thoracic endovascular aortic repair (TEVAR) is increasingly performed in patients with uncomplicated dissections and high-risk features in the subacute phase (14-90 days) to promote false lumen thrombosis and prevent aneurysmal degeneration.[10] However, there is considerable heterogeneity of published data; results from meta-analyses evaluating TEVAR in patients with type B aortic dissection should be interpreted with caution.

One meta-analysis found no evidence for survival benefit at 1 year for patients with acute uncomplicated type B aortic dissection (TBAD) treated with TEVAR compared with those receiving best medical therapy.[49] Another meta-analysis found that TEVAR did not prevent aneurysmal degeneration in patients treated for acute or chronic (including complicated) TBAD, noting that long-term data are lacking.[50] Results from one meta-analysis of a mixed patient population (complicated/uncomplicated, acute/subacute TBAD) and one randomized study of patients with stable TBAD, respectively, suggest that aneurysm-specific outcomes may be favorable over the longer term following TEVAR.[51][52] Larger trials with longer-term data are still required.[4]

There may be some benefit to early endovascular intervention in patients with uncomplicated acute type B aortic dissection with refractory pain and hypertension.[53] TEVAR in the subacute phase of type B dissection may be associated with a lower risk of complications, particularly retrograde type A dissection.[54]

ONGOING

chronic (all types)

1st line – antihypertensive therapy

Consider – open surgery or endovascular stent-graft repair

Back

Consider –

open surgery or endovascular stent-graft repair

Treatment recommended for SOME patients in selected patient group

Patients with chronic aortic dissection will require long-term follow-up with surveillance imaging (the time intervals for this will vary between individuals) and may need open surgical repair or endovascular therapy (thoracic endovascular aortic repair [TEVAR]) in their lifetime.[23] Some patients will not have open surgical repair or TEVAR previously while others might have one of the procedures for the second time.

Indications for surgery in uncomplicated chronic aortic dissections depend on aortic diameter, pathogenesis, and the presence of symptoms. Asymptomatic chronic thoracic and thoracoabdominal aortic dissections with a maximal orthogonal aortic diameter of 6.0 cm in patients without connective tissue disease warrant repair.[23][56] Rapid growth rate >0.5 cm per year also may be an indication for repair.[23] Patients with connective tissue diseases and those with a family history warrant more careful consideration and may warrant earlier intervention (diameter of 5.0 to 5.5 cm).[23][57][58]

TEVAR has been increasingly used for thoracic and thoracoabdominal aortic aneurysm repair occurring after aortic dissection because of the low acute risk compared with open repair and the potential to reduce aortic mortality and reoperations compared with medical therapy.[23] However, TEVAR faces anatomic and morphologic limitations to successfully treating this disease, particularly in the chronic stage.[23][59][60][61][62] TEVAR may be a viable rescue option for patients with type A dissection who are not eligible for open surgical repair.[63]

The goals of TEVAR therapy are to: cover the entry tear; treat or prevent impending rupture; re-establish organ perfusion; restore flow in the true lumen; and induce the false lumen thrombosis.

One Cochrane review noted a lack of clinical trials investigating the effectiveness and safety of TEVAR compared with open surgical repair for patients with complicated chronic type B aortic dissection. The investigators were therefore unable to provide any evidence to inform decision-making on the optimal intervention for these patients.[64] In a retrospective analysis of 80 patients who underwent TEVAR for chronic type B aortic dissections, complete false lumen thrombosis was achieved in 52% and aneurysm diameter was stabilized or reduced in 65%; 5-year overall survival was 70%.[59]

In a prospective multicenter trial from China, TEVAR for chronic type B aortic dissection decreased the risk of aortic-related mortality compared with optimal medical therapy alone at 4 years, but failed to improve overall survival. The thoracic aorta diameter decreased significantly in the TEVAR group, but increased in the medical therapy group.[65]

There currently are no longer-term data on the efficacy of TEVAR for chronic type B aortic dissection.

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Aortic dissection

hemodynamically unstable: suspected aortic dissection

advanced life support with hemodynamic support

confirmed aortic dissection

beta-blocker or nondihydropyridine calcium-channel blocker

Primary options

Secondary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Secondary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

Secondary options

opioid analgesia

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

vasodilator

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

type A

open surgery or endovascular stent-graft repair

type B with complications (rupture, visceral/extremity ischemia, expansion, or persistent pain)

endovascular stent-graft repair or open surgery

type B uncomplicated

consider endovascular stent-graft repair

chronic (all types)

antihypertensive therapy

open surgery or endovascular stent-graft repair

Aortic dissection

Treatment algorithm

hemodynamically unstable: suspected aortic dissection

advanced life support with hemodynamic support

confirmed aortic dissection

beta-blocker or nondihydropyridine calcium-channel blocker

Primary options

Secondary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Secondary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

Secondary options

opioid analgesia

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

vasodilator

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

type A

open surgery or endovascular stent-graft repair

type B with complications (rupture, visceral/extremity ischemia, expansion, or persistent pain)

endovascular stent-graft repair or open surgery

type B uncomplicated

consider endovascular stent-graft repair

chronic (all types)

antihypertensive therapy

open surgery or endovascular stent-graft repair