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 used 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'.)
- DEBAKEY ME, HENLY WS, COOLEY DA, et al. SURGICAL MANAGEMENT OF DISSECTING ANEURYSMS OF THE AORTA. J Thorac Cardiovasc Surg 1965; 49:130.
- Daily PO, Trueblood HW, Stinson EB, et al. Management of acute aortic dissections. Ann Thorac Surg 1970; 10:237.
- Erbel R, Aboyans V, Boileau C, et al. [2014 ESC Guidelines on the diagnosis and treatment of aortic diseases]. Kardiol Pol 2014; 72:1169.
- Fattori R, Cao P, De Rango P, et al. Interdisciplinary expert consensus document on management of type B aortic dissection. J Am Coll Cardiol 2013; 61:1661.
- Hiratzka LF, Bakris GL, Beckman JA, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation 2010; 121:e266.
- Tsai TT, Nienaber CA, Eagle KA. Acute aortic syndromes. Circulation 2005; 112:3802.
- Nienaber CA, Eagle KA. Aortic dissection: new frontiers in diagnosis and management: Part I: from etiology to diagnostic strategies. Circulation 2003; 108:628.
- Hagan PG, Nienaber CA, Isselbacher EM, et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA 2000; 283:897.
- Doroghazi RM, Slater EE, DeSanctis RW, et al. Long-term survival of patients with treated aortic dissection. J Am Coll Cardiol 1984; 3:1026.
- Mehta RH, Suzuki T, Hagan PG, et al. Predicting death in patients with acute type a aortic dissection. Circulation 2002; 105:200.
- Kawahito K, Adachi H, Yamaguchi A, Ino T. Early and late surgical outcomes of acute type A aortic dissection in patients aged 75 years and older. Ann Thorac Surg 2000; 70:1455.
- Miller DC, Mitchell RS, Oyer PE, et al. Independent determinants of operative mortality for patients with aortic dissections. Circulation 1984; 70:I153.
- Haverich A, Miller DC, Scott WC, et al. Acute and chronic aortic dissections--determinants of long-term outcome for operative survivors. Circulation 1985; 72:II22.
- Pansini S, Gagliardotto PV, Pompei E, et al. Early and late risk factors in surgical treatment of acute type A aortic dissection. Ann Thorac Surg 1998; 66:779.
- Sabik JF, Lytle BW, Blackstone EH, et al. Long-term effectiveness of operations for ascending aortic dissections. J Thorac Cardiovasc Surg 2000; 119:946.
- Kawahito K, Adachi H, Yamaguchi A, Ino T. Preoperative risk factors for hospital mortality in acute type A aortic dissection. Ann Thorac Surg 2001; 71:1239.
- Lai DT, Robbins RC, Mitchell RS, et al. Does profound hypothermic circulatory arrest improve survival in patients with acute type a aortic dissection? Circulation 2002; 106:I218.
- DE BAKEY ME, COOLEY DA, CREECH O Jr. Surgical considerations of dissecting aneurysm of the aorta. Ann Surg 1955; 142:586.
- Chiappini B, Schepens M, Tan E, et al. Early and late outcomes of acute type A aortic dissection: analysis of risk factors in 487 consecutive patients. Eur Heart J 2005; 26:180.
- Mehta RH, O'Gara PT, Bossone E, et al. Acute type A aortic dissection in the elderly: clinical characteristics, management, and outcomes in the current era. J Am Coll Cardiol 2002; 40:685.
- Nienaber CA, Fattori R, Mehta RH, et al. Gender-related differences in acute aortic dissection. Circulation 2004; 109:3014.
- Penn MS, Smedira N, Lytle B, Brener SJ. Does coronary angiography before emergency aortic surgery affect in-hospital mortality? J Am Coll Cardiol 2000; 35:889.
- Movsowitz HD, Levine RA, Hilgenberg AD, Isselbacher EM. Transesophageal echocardiographic description of the mechanisms of aortic regurgitation in acute type A aortic dissection: implications for aortic valve repair. J Am Coll Cardiol 2000; 36:884.
- Bossone E, Rampoldi V, Nienaber CA, et al. Usefulness of pulse deficit to predict in-hospital complications and mortality in patients with acute type A aortic dissection. Am J Cardiol 2002; 89:851.
- Ehrlich MP, Schillinger M, Grabenwöger M, et al. Predictors of adverse outcome and transient neurological dysfunction following surgical treatment of acute type A dissections. Circulation 2003; 108 Suppl 1:II318.
- Collins JS, Evangelista A, Nienaber CA, et al. Differences in clinical presentation, management, and outcomes of acute type a aortic dissection in patients with and without previous cardiac surgery. Circulation 2004; 110:II237.
- DeSanctis RW, Doroghazi RM, Austen WG, Buckley MJ. Aortic dissection. N Engl J Med 1987; 317:1060.
- Moon MR, Sundt TM 3rd, Pasque MK, et al. Does the extent of proximal or distal resection influence outcome for type A dissections? Ann Thorac Surg 2001; 71:1244.
- Kazui T, Washiyama N, Muhammad BA, et al. Extended total arch replacement for acute type a aortic dissection: experience with seventy patients. J Thorac Cardiovasc Surg 2000; 119:558.
- Chen LW, Dai XF, Lu L, et al. Extensive primary repair of the thoracic aorta in acute type a aortic dissection by means of ascending aorta replacement combined with open placement of triple-branched stent graft: early results. Circulation 2010; 122:1373.
- Uchida N, Shibamura H, Katayama A, et al. Operative strategy for acute type a aortic dissection: ascending aortic or hemiarch versus total arch replacement with frozen elephant trunk. Ann Thorac Surg 2009; 87:773.
- Murzi M, Tiwari KK, Farneti PA, Glauber M. Might type A acute dissection repair with the addition of a frozen elephant trunk improve long-term survival compared to standard repair? Interact Cardiovasc Thorac Surg 2010; 11:98.
- Uchida N, Katayama A, Tamura K, et al. Long-term results of the frozen elephant trunk technique for extended aortic arch disease. Eur J Cardiothorac Surg 2010; 37:1338.
- Gorlitzer M, Weiss G, Meinhart J, et al. Fate of the false lumen after combined surgical and endovascular repair treating Stanford type A aortic dissections. Ann Thorac Surg 2010; 89:794.
- Pichlmaier MA, Teebken OE, Khaladj N, et al. Distal aortic surgery following arch replacement with a frozen elephant trunk. Eur J Cardiothorac Surg 2008; 34:600.
- Mestres CA, Fernández C, Josa M, Mulet J. Hybrid antegrade repair of the arch and descending thoracic aorta with a new integrated stent-Dacron graft in acute type A aortic dissection: a look into the future with new devices. Interact Cardiovasc Thorac Surg 2007; 6:257.
- Baraki H, Hagl C, Khaladj N, et al. The frozen elephant trunk technique for treatment of thoracic aortic aneurysms. Ann Thorac Surg 2007; 83:S819.
- Schoenhoff FS, Schmidli J, Eckstein FS, et al. The frozen elephant trunk: an interesting hybrid endovascular-surgical technique to treat complex pathologies of the thoracic aorta. J Vasc Surg 2007; 45:597.
- Karck M, Kamiya H. Progress of the treatment for extended aortic aneurysms; is the frozen elephant trunk technique the next standard in the treatment of complex aortic disease including the arch? Eur J Cardiothorac Surg 2008; 33:1007.
- Roselli EE, Soltesz EG, Mastracci T, et al. Antegrade delivery of stent grafts to treat complex thoracic aortic disease. Ann Thorac Surg 2010; 90:539.
- Baraki H, Al Ahmad A, Sarikouch S, et al. The first fifty consecutive Bentall operations with a prefabricated tissue-valved aortic conduit: a single-center experience. J Heart Valve Dis 2010; 19:286.
- Karck M, Chavan A, Khaladj N, et al. The frozen elephant trunk technique for the treatment of extensive thoracic aortic aneurysms: operative results and follow-up. Eur J Cardiothorac Surg 2005; 28:286.
- Karck M, Chavan A, Hagl C, et al. The frozen elephant trunk technique: a new treatment for thoracic aortic aneurysms. J Thorac Cardiovasc Surg 2003; 125:1550.
- Usui A, Fujimoto K, Ishiguchi T, et al. Cerebrospinal dysfunction after endovascular stent-grafting via a median sternotomy: the frozen elephant trunk procedure. Ann Thorac Surg 2002; 74:S1821.
- Kusagawa H, Shimono T, Ishida M, et al. Changes in false lumen after transluminal stent-graft placement in aortic dissections: six years' experience. Circulation 2005; 111:2951.
- Duebener LF, Lorenzen P, Richardt G, et al. Emergency endovascular stent-grafting for life-threatening acute type B aortic dissections. Ann Thorac Surg 2004; 78:1261.
- Slonim SM, Miller DC, Mitchell RS, et al. Percutaneous balloon fenestration and stenting for life-threatening ischemic complications in patients with acute aortic dissection. J Thorac Cardiovasc Surg 1999; 117:1118.
- Erbel R, Alfonso F, Boileau C, et al. Diagnosis and management of aortic dissection. Eur Heart J 2001; 22:1642.
- Crawford ES. The diagnosis and management of aortic dissection. JAMA 1990; 264:2537.
- Nienaber CA, Rousseau H, Eggebrecht H, et al. Randomized comparison of strategies for type B aortic dissection: the INvestigation of STEnt Grafts in Aortic Dissection (INSTEAD) trial. Circulation 2009; 120:2519.
- Hughes GC. Management of acute type B aortic dissection; ADSORB trial. J Thorac Cardiovasc Surg 2015; 149:S158.
- Nauta FJ, Trimarchi S, Kamman AV, et al. Update in the management of type B aortic dissection. Vasc Med 2016; 21:251.
- Qin YL, Wang F, Li TX, et al. Endovascular Repair Compared With Medical Management of Patients With Uncomplicated Type B Acute Aortic Dissection. J Am Coll Cardiol 2016; 67:2835.
- Nienaber CA, Clough RE. Management of acute aortic dissection. Lancet 2015; 385:800.
- Suzuki T, Mehta RH, Ince H, et al. Clinical profiles and outcomes of acute type B aortic dissection in the current era: lessons from the International Registry of Aortic Dissection (IRAD). Circulation 2003; 108 Suppl 1:II312.
- Ulug P, McCaslin JE, Stansby G, Powell JT. Endovascular versus conventional medical treatment for uncomplicated chronic type B aortic dissection. Cochrane Database Syst Rev 2012; 11:CD006512.
- Brunkwall J, Lammer J, Verhoeven E, Taylor P. ADSORB: a study on the efficacy of endovascular grafting in uncomplicated acute dissection of the descending aorta. Eur J Vasc Endovasc Surg 2012; 44:31.
- Brunkwall J, Kasprzak P, Verhoeven E, et al. Endovascular repair of acute uncomplicated aortic type B dissection promotes aortic remodelling: 1 year results of the ADSORB trial. Eur J Vasc Endovasc Surg 2014; 48:285.
- Umaña JP, Lai DT, Mitchell RS, et al. Is medical therapy still the optimal treatment strategy for patients with acute type B aortic dissections? J Thorac Cardiovasc Surg 2002; 124:896.
- Bernard Y, Zimmermann H, Chocron S, et al. False lumen patency as a predictor of late outcome in aortic dissection. Am J Cardiol 2001; 87:1378.
- Estrera AL, Miller CC 3rd, Safi HJ, et al. Outcomes of medical management of acute type B aortic dissection. Circulation 2006; 114:I384.
- Erbel R, Oelert H, Meyer J, et al. Effect of medical and surgical therapy on aortic dissection evaluated by transesophageal echocardiography. Implications for prognosis and therapy. The European Cooperative Study Group on Echocardiography. Circulation 1993; 87:1604.
- Tsai TT, Evangelista A, Nienaber CA, et al. Partial thrombosis of the false lumen in patients with acute type B aortic dissection. N Engl J Med 2007; 357:349.
- Nienaber CA, Kische S, Rousseau H, et al. Endovascular repair of type B aortic dissection: long-term results of the randomized investigation of stent grafts in aortic dissection trial. Circ Cardiovasc Interv 2013; 6:407.
- Januzzi JL, Movsowitz HD, Choi J, et al. Significance of recurrent pain in acute type B aortic dissection. Am J Cardiol 2001; 87:930.
- Trimarchi S, Eagle KA, Nienaber CA, et al. Importance of refractory pain and hypertension in acute type B aortic dissection: insights from the International Registry of Acute Aortic Dissection (IRAD). Circulation 2010; 122:1283.
- Dake MD, Kato N, Mitchell RS, et al. Endovascular stent-graft placement for the treatment of acute aortic dissection. N Engl J Med 1999; 340:1546.
- Eggebrecht H, Nienaber CA, Neuhäuser M, et al. Endovascular stent-graft placement in aortic dissection: a meta-analysis. Eur Heart J 2006; 27:489.
- Trimarchi S, Nienaber CA, Rampoldi V, et al. Role and results of surgery in acute type B aortic dissection: insights from the International Registry of Acute Aortic Dissection (IRAD). Circulation 2006; 114:I357.
- Glower DD, Speier RH, White WD, et al. Management and long-term outcome of aortic dissection. Ann Surg 1991; 214:31.
- Fattori R, Bacchi-Reggiani L, Bertaccini P, et al. Evolution of aortic dissection after surgical repair. Am J Cardiol 2000; 86:868.
- Song JM, Kim SD, Kim JH, et al. Long-term predictors of descending aorta aneurysmal change in patients with aortic dissection. J Am Coll Cardiol 2007; 50:799.
- Halstead JC, Meier M, Etz C, et al. The fate of the distal aorta after repair of acute type A aortic dissection. J Thorac Cardiovasc Surg 2007; 133:127.
- Isselbacher EM. Dissection of the descending thoracic aorta: looking into the future. J Am Coll Cardiol 2007; 50:805.
- Tsai TT, Evangelista A, Nienaber CA, et al. Long-term survival in patients presenting with type A acute aortic dissection: insights from the International Registry of Acute Aortic Dissection (IRAD). Circulation 2006; 114:I350.
- 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