Suspected Acute Aortic Dissection
Sudden severe chest/back pain, often described as tearing or ripping
All Pathways
Vascular SurgeryEmergency
Acute Aortic Dissection Management (ESC 2024)
Acute Aortic Dissection Management (ESC 2024): Suspected Acute Aortic Dissection → Clinical Recognition → Immediate Medical Management → TEM Classificat...
Pathway Overview
17 steps
Algorithm Steps
17 total
01Start 02Action 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
03Action 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
04Decision 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
05Warning 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
06Action 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
07Action 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
08Action 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)
09Outcome Survival
Type A surgery: 70-85% survival; Type B medical: >90%; Complicated Type B TEVAR: 80-90%
10Action 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
11Outcome Long-term Considerations
Re-intervention rate 10-20%; lifelong surveillance required
12Decision Type B Dissection
Evaluate for complications
- Starts distal to left subclavian
- Complicated vs uncomplicated determines treatment
- Complicated: malperfusion, rupture, refractory HTN, rapid expansion
13Action 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
- Path rejoins step 07Shared downstream outcome
14Warning 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
15Action 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
16Action 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
- Path rejoins step 07Shared downstream outcome
- Path rejoins step 16Shared downstream outcome
17Action 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
- Path rejoins step 04Shared downstream outcome
Guideline Source
ESC 2024 Guidelines for the Management of Peripheral Arterial and Aortic Diseases
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Type A requires emergent cardiac surgery - transfer if not available
- Multidisciplinary aortic team essential for complex cases
- TEM classification is new (2024) - may evolve
- Does not cover aortic intramural hematoma or penetrating ulcer in detail
- Genetic testing/counseling for connective tissue disorders separate process
Applicable Regions
USEUGlobal
EU: ESC 2024 is current standard; TEM classification newly introduced
US: ACC/AHA guidelines similar principles; institutional protocols vary
Version 1Next review: 2027-01-01
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Related Resources
Frequently Asked Questions
What is the Acute Aortic Dissection Management (ESC 2024)?
The Acute Aortic Dissection Management (ESC 2024) is a emergency clinical algorithm for Vascular Surgery. It provides a structured decision tree to guide clinical decision-making, based on ESC 2024 Guidelines for the Management of Peripheral Arterial and Aortic Diseases.
What guideline is the Acute Aortic Dissection Management (ESC 2024) based on?
This algorithm is based on ESC 2024 Guidelines for the Management of Peripheral Arterial and Aortic Diseases (DOI: 10.1093/eurheartj/ehae179).
What are the limitations of the Acute Aortic Dissection Management (ESC 2024)?
Known limitations include: Type A requires emergent cardiac surgery - transfer if not available; Multidisciplinary aortic team essential for complex cases; TEM classification is new (2024) - may evolve; Does not cover aortic intramural hematoma or penetrating ulcer in detail; Genetic testing/counseling for connective tissue disorders separate process. Individual patient factors may require deviation from these recommendations.
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