Management of acute aortic dissection
- James H Black, III, MD
James H Black, III, MD
- Associate Professor of Surgery
- Johns Hopkins University
- Warren J Manning, MD
Warren J Manning, MD
- Section Editor — Noninvasive Cardiac Imaging and Stress Testing
- Professor of Medicine and Radiology
- Harvard Medical School
- Section Editors
- Emile R Mohler III, MD
Emile R Mohler III, MD
- Section Editor — Vascular Medicine
- Professor of Medicine
- University of Pennsylvania School of Medicine
- Gabriel S Aldea, MD
Gabriel S Aldea, MD
- Section Editor — Cardiac Surgery
- Professor of Surgery
- University of Washington
- Edward Verrier, MD
Edward Verrier, MD
- Section Editor — Cardiac Surgery
- Professor of Surgery
- University of Washington School of Medicine
Thoracic aortic dissection is usually suspected clinically from the history and physical examination when a patient presents with severe, sharp, or "tearing" anterior chest pain (in ascending aortic dissection) or posterior chest or back pain (in dissection distal to the left subclavian). This potential diagnosis can be easily overlooked among patients with acute chest pain, and a high index of suspicion is needed to obtain an accurate diagnosis such that appropriate initial therapy can be instituted promptly. Advances in imaging and better awareness have improved the diagnosis, which is confirmed using advanced cardiovascular imaging.
The DeBakey and the Stanford (Daily) systems are used to classify aortic dissection (figure 1) [1,2]. The Stanford system, which is more widely used, classifies dissections that involve the ascending aorta as type A, regardless of the site of the primary intimal tear; all other dissections are classified as type B.
The goals of acute management of the dissection are to control pain and limit the extent of the dissection using anti-impulse therapy, which typically involves administration of beta blockers. Definitive management differs for ascending (type A) and descending (type B) thoracic aortic dissection, and thus, early determination of which segments of the aorta are involved is important.
The management of acute aortic dissection will be reviewed here. The recommendations are generally in agreement with multidisciplinary cardiovascular guidelines [3-5]. The clinical evaluation and diagnosis of aortic dissection are reviewed separately. Management of other acute aortic syndromes is discussed separately. (See "Clinical features and diagnosis of acute aortic dissection" and "Overview of acute aortic syndromes" and "Overview of acute aortic syndromes", section on 'Definition and pathophysiology'.)
ACUTE MEDICAL MANAGEMENT
Acute medical management of acute aortic syndromes including aortic dissection involves controlling pain, and providing anti-impulse therapy in the form of blood pressure lowering and decreasing the velocity of left ventricular contraction, to decrease aortic shear stress and minimize the tendency for the dissection to propagate. Medications and dosing use in acute aortic dissection are similar to other acute aortic syndromes and are reviewed separately. (See "Overview of acute aortic syndromes", section on 'Acute medical management'.)
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- ACUTE MEDICAL MANAGEMENT
- TYPE AND ETIOLOGY OF DISSECTION
- Extent and classification
- ASCENDING (TYPE A) AORTIC DISSECTION
- Efficacy of intervention
- Medical risk assessment
- - Prognostic factors
- Extent of open repair
- Role for endovascular repair
- DESCENDING (TYPE B) AORTIC DISSECTION
- Efficacy of medical management
- - Endovascular repair
- - Open repair
- LONG-TERM MANAGEMENT
- Anti-impulse therapy
- Serial imaging
- Reintervention for endograft complications
- MORBIDITY AND MORTALITY
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS