Acute Type A Aortic Dissection Management (EACTS/STS 2024)

Algorithm Steps

1. ▶

   Start

   Suspected Acute Type A Aortic Dissection

   Patient with sudden severe chest/back pain, BP differential, widened mediastinum, or aortic regurgitation

   1. ●

      Action

      Immediate Stabilization

      Anti-impulse therapy while confirming diagnosis

      • IV access, arterial line (right radial preferred)
      • Target HR <60 bpm: IV beta-blocker (esmolol/labetalol)
      • Target SBP 100-120 mmHg
      • Pain control: IV morphine/fentanyl
      • Type and crossmatch 6+ units PRBCs
      • STAT CT angiography chest/abdomen/pelvis
      1. ◆

         Decision

         CTA Confirms Type A Dissection?

         Intimal flap involving ascending aorta (Stanford A)

         • Assess TEM classification:
         • T: Type (A/B, A1-A3)
         • E: Entry location (0-3)
         • M: Malperfusion (0-3)
         1. ◆

            Decision

            Malperfusion Present?

            Assess for end-organ ischemia

            • Coronary: STEMI, cardiogenic shock
            • Cerebral: stroke, altered mental status
            • Mesenteric: abdominal pain, lactate elevation
            • Renal: oliguria, rising creatinine
            • Limb: pulse deficit, limb ischemia
            1. ●

               Action

               EMERGENCY SURGERY

               Class I, Level B Recommendation

               • Immediate OR mobilization
               • Notify cardiac surgery, anesthesia, perfusion
               • Goal: minimize time to surgery
               • Do NOT delay for additional imaging
               1. ●

                  Action

                  Cannulation Strategy

                  Antegrade perfusion preferred (Class IIa)

                  • Preferred: Right axillary artery cannulation
                  • Alternative: Direct aortic (if axillary not feasible)
                  • Femoral: Use with caution (retrograde perfusion risk)
                  • Central cannulation if hemodynamically unstable
                  1. ●

                     Action

                     Surgical Repair

                     Tear-oriented approach with open distal anastomosis

                     • Median sternotomy
                     • Hypothermic circulatory arrest (HCA)
                     • Cerebral protection: antegrade cerebral perfusion
                     • Resect primary entry tear
                     • Open distal anastomosis during HCA (Class I)
                     • Ascending aorta ± hemiarch replacement
                     • Root: repair or replacement based on anatomy
                     1. ●

                        Action

                        Post-Operative Management

                        ICU care and surveillance

                        • BP control: SBP 100-120 mmHg
                        • Neurologic monitoring
                        • Bleeding surveillance
                        • Serial imaging at 1 month, 6 months, annually
                        • Lifelong beta-blocker therapy
                        1. ✓

                           Outcome

                           Survived to Discharge

                           Long-term surveillance required

                        2. ⚠

                           Warning

                           High Mortality Risk

                           30-day mortality 15-25% in experienced centers

            2. ●

               Action

               Address Malperfusion

               May require staged approach

               • Coronary: central repair often restores flow
               • Cerebral: proceed with surgery despite stroke (Class IIa)
               • Mesenteric: may need post-op intervention
               • Limb: may need endovascular/surgical adjunct
            3. ●

               Action

               Calculate GERAADA Score

               Predict 30-day mortality (Class IIa, Level C)

               • Age, preoperative state, intubation
               • Malperfusion status
               • Hemodynamic instability
               • Used for risk stratification and family discussion
         2. ●

            Action

            Not Type A

            If type B or intramural hematoma

            • Type B: Medical management unless complicated
            • IMH: Treat similar to dissection type
            • Consider alternative diagnoses
      2. ⚠

         Warning

         ⚠️ Watch for Tamponade

         Pericardial effusion with dissection = impending rupture. Do NOT perform pericardiocentesis - proceed directly to OR