Acute Aortic Dissection Management (ESC 2024)

Algorithm Steps

1. ▶

   Start

   Suspected Acute Aortic Dissection

   Sudden severe chest/back pain, often described as tearing or ripping

   1. ●

      Action

      Clinical Recognition

      High index of suspicion critical

      • Sudden onset severe pain (chest, back, abdomen)
      • Tearing/ripping quality (50%)
      • Hypertension or hypotension
      • Pulse deficit, BP differential >20 mmHg
      • Neurological symptoms (stroke, paraplegia)
      • Risk: HTN, Marfan, bicuspid aortic valve, prior aortic disease
      1. ●

         Action

         Immediate Medical Management

         Anti-impulse therapy - reduce shear stress

         • Target SBP <120 mmHg (ideally 100-120)
         • Target HR <60 bpm
         • IV beta-blocker FIRST (esmolol, labetalol)
         • Then add vasodilator if needed (nicardipine, nitroprusside)
         • Adequate analgesia (opioids)
         • Large bore IV access, type & screen
         1. ◆

            Decision

            TEM Classification (ESC 2024)

            Type - Entry - Malperfusion

            • T: Type A (involves ascending) vs Type B (distal to left subclavian)
            • E: Entry tear location (arch zones 0-4)
            • M: Malperfusion present (coronary, cerebral, visceral, limb)
            • Determines urgency and treatment approach
            1. ⚠

               Warning

               Type A Dissection

               SURGICAL EMERGENCY - involves ascending aorta

               • Mortality 1-2% per hour without surgery
               • Emergent surgical repair (Class I)
               • Ascending aorta ± arch replacement
               • Address aortic root if involved (Bentall, valve-sparing)
               • Transfer immediately if no cardiac surgery
               1. ●

                  Action

                  Surgical Repair (Type A)

                  Emergent open repair

                  • Ascending aorta replacement (tube or hemiarch)
                  • Deep hypothermic circulatory arrest
                  • Aortic root: reimplant, Bentall, or valve-sparing
                  • Extended arch if entry in arch
                  • Elephant trunk/FET for extensive disease
                  1. ●

                     Action

                     Post-Procedure Care

                     ICU monitoring and surveillance

                     • Continue anti-impulse therapy
                     • Monitor for spinal cord ischemia
                     • Renal function monitoring
                     • Serial imaging: CTA before discharge, then 1, 3, 6, 12 months
                     • Lifelong BP control
                     1. ●

                        Action

                        Long-Term Management

                        Lifelong surveillance required

                        • Strict BP control (<120/80 mmHg)
                        • Beta-blocker based regimen
                        • Annual CT or MRI surveillance
                        • Genetic testing if <60 years or family hx
                        • Family screening for heritable aortopathies
                        • Activity restriction (no heavy lifting, isometric exercise)
                        1. ✓

                           Outcome

                           Survival

                           Type A surgery: 70-85% survival; Type B medical: >90%; Complicated Type B TEVAR: 80-90%

                     2. ●

                        Action

                        Genetic Considerations

                        Heritable thoracic aortic disease

                        • Marfan syndrome (FBN1)
                        • Loeys-Dietz syndrome (TGFBR1/2)
                        • Vascular Ehlers-Danlos (COL3A1)
                        • Bicuspid aortic valve (NOTCH1)
                        • Refer to genetics if suspected
                        1. ✓

                           Outcome

                           Long-term Considerations

                           Re-intervention rate 10-20%; lifelong surveillance required

            2. ◆

               Decision

               Type B Dissection

               Evaluate for complications

               • Starts distal to left subclavian
               • Complicated vs uncomplicated determines treatment
               • Complicated: malperfusion, rupture, refractory HTN, rapid expansion
               1. ●

                  Action

                  Uncomplicated Type B

                  Optimal Medical Therapy

                  • Continue anti-impulse therapy
                  • Target SBP <120 mmHg
                  • Beta-blocker based regimen
                  • ICU monitoring initially
                  • Serial imaging (CTA at 3-7 days)
                  • Consider TEVAR in subacute phase if aortic growth
               2. ⚠

                  Warning

                  Complicated Type B

                  Requires urgent intervention

                  • TEVAR preferred over open surgery (Class I)
                  • Indications: malperfusion syndrome, rupture/contained rupture
                  • Refractory pain, uncontrolled HTN despite max therapy
                  • Rapid aortic expansion
                  • May need additional fenestration or branch stenting
                  1. ●

                     Action

                     Malperfusion Syndrome

                     Branch vessel compromise

                     • Static: branch vessel covered by flap
                     • Dynamic: true lumen collapse
                     • Visceral ischemia: mesenteric, renal
                     • Limb ischemia: lower extremity malperfusion
                     • TEVAR restores true lumen; may need additional stenting
                     1. ●

                        Action

                        TEVAR

                        Thoracic endovascular aortic repair

                        • Cover primary entry tear
                        • Promote false lumen thrombosis
                        • Zone 2 or distal landing
                        • May need carotid-subclavian bypass if covering left subclavian
                        • CSF drainage if extensive coverage
      2. ●

         Action

         CT Angiography (CTA)

         Gold standard imaging

         • ECG-gated CTA preferred
         • Entire aorta (root to bifurcation)
         • Identifies: intimal flap, true/false lumen
         • Entry tear location
         • Branch vessel involvement (malperfusion)
         • TEE alternative if CTA not available