Suspected Acute Type A Aortic Dissection (Adult)
Pain with pulse deficit or arm BP difference, new aortic regurgitation murmur, or ascending aorta flap on imaging. Call cardiothoracic surgery now.
All Pathways
Cardiothoracic SurgeryEmergency
Acute Type A Aortic Dissection Management (EACTS/STS 2024)
Acute Type A Aortic Dissection Management (EACTS/STS 2024): Suspected Acute Type A Aortic Dissection (Adult) → Suspected Dissection: No Thrombolysis → H...
Pathway Overview
15 steps
Algorithm Steps
15 total
01Start 02Warning Suspected Dissection: No Thrombolysis
Coronary malperfusion can look like STEMI and cerebral malperfusion like stroke. Image the aorta first.
- Thrombolysis is contraindicated in suspected or confirmed aortic dissection
- Do not start aspirin, P2Y12 inhibitor or heparin loading until dissection is excluded, unless the treating specialist decides
- Stroke with chest or back pain: image the aorta before thrombolysis
03Warning Hypotension, Shock or Tamponade: No Beta-Blocker or Vasodilator
SBP <90 mmHg or shock (tamponade, rupture, severe acute aortic regurgitation, coronary malperfusion). Resuscitate and go straight to theatre.
- Bedside TTE now (effusion, AR, flap); TOE if too unstable for CT
- Tamponade: straight to theatre. Pericardial drainage only as a bridge in arrest or extremis: small, controlled volumes to keep SBP about 90 mmHg
- No cardiac surgery on site: call the cardiac surgical centre and retrieval service at once
04Warning Not Shocked: Check Before Anti-Impulse Therapy
Pregnancy: obstetric and aortic teams; labetalol is the usual beta-blocker.
- Beta-blocker contraindicated (e.g. severe asthma): IV verapamil for rate control
- Bradycardia, heart block, decompensated heart failure or severe acute aortic regurgitation: no rate-control drug (no beta-blocker, no verapamil); urgent specialist advice
- Malperfusion, spinal cord ischaemia or brain injury: accept a higher BP (MAP) to keep perfusion
05Action Not Shocked: Anti-Impulse Therapy
Target heart rate 60 b.p.m. or less and SBP <120 mmHg (lowest BP that keeps organ perfusion). Do not delay surgery.
- First: IV beta-blocker (labetalol or esmolol) to heart rate 60 b.p.m. or less
- Then, only if SBP is still 120 mmHg or more: add IV vasodilator (GTN or nitroprusside; clevidipine where stocked)
- Never start a vasodilator before rate control (reflex tachycardia)
- IV opioid analgesia
- Arterial line in the arm with the higher BP; crossmatch blood
- Dose: see local protocol and product information
06Decision Imaging Confirms Type A (Ascending Aorta Involved)?
ECG-gated CT angiography neck to pelvis; TOE if unstable. Type A intramural haematoma counts as type A.
- TEM: T type (A), E entry site (E0 not seen, E1 ascending, E2 arch, E3 descending), M malperfusion (M0-M3)
- Do not delay theatre for more imaging
- If Yes
07Action Confirmed Type A: Transfer Now If No Cardiac Surgery On Site
No cardiac surgery on site: call the cardiac surgical centre and retrieval service at once; do not delay for more imaging. Cardiac surgery on site: go to the next step.
- Low-volume centre: transfer to a high-volume aortic centre if this does not delay surgery (Class IIa)
- Continue anti-impulse therapy only if not shocked
08Decision Confirmed Type A: Malperfusion?
Check coronary, cerebral, spinal, mesenteric, renal and limb perfusion. Either way, go on to surgery.
- Coronary: ischaemic ECG, cardiogenic shock
- Cerebral or spinal: stroke, altered consciousness, paraplegia
- Mesenteric: abdominal pain, rising lactate, abnormal liver tests
- Renal: oliguria, rising creatinine
- Limb: pulse deficit, ischaemic limb
- If Yes
09Action Type A With Malperfusion: Immediate Aortic Surgery
Immediate central aortic repair (Class I). Haemorrhagic or completed stroke: immediate surgery may be unwise; aortic team decides.
- Cerebral malperfusion or non-haemorrhagic stroke: immediate surgery should be considered (Class IIa)
- Significant mesenteric malperfusion: immediate angiography and percutaneous repair before or directly after surgery, in expert centres (ESC Class IIa; EACTS/STS IIb)
- Persistent malperfusion after repair: angiography, percutaneous repair or TEVAR
10Action Confirmed Type A: Emergency Surgery
Dissection: immediate theatre (Class I). Type A intramural haematoma (IMH): emergency surgery if complicated or high-risk features; otherwise urgent surgery, aortic team sets timing. Notify cardiac surgery, anaesthesia and perfusion.
- Pregnant with viable fetus: caesarean delivery before aortic repair
- Age alone is not a reason to withhold surgery
- Peri-operative mortality 17-25%; GERAADA score may be used to estimate 30-day risk (Class IIa)
- On anticoagulant, or already given antiplatelet or heparin: tell surgery and anaesthesia; plan reversal and blood products. Do not delay surgery
- IMH high-risk features: age over 70, aortic diameter over 45 mm, haematoma thickness 10 mm or more, ulcer-like projection, pleural effusion. Complicated: malperfusion, rupture, recurrent pain
11Action Cannulation and Cerebral Protection
Axillary cannulation when feasible, over femoral (Class IIa).
- Alternative: direct aortic or innominate cannulation with imaging guidance (Class IIa)
- Femoral: fastest in unstable patients; higher risk of stroke and retrograde malperfusion
- Circulatory arrest: use cerebral perfusion (Class IIa)
12Action Surgical Repair
Resect the primary entry tear and replace the ascending aorta with an open distal anastomosis (Class I).
- Hemiarch unless arch tear or significant arch aneurysm (Class I)
- Tear in arch or proximal descending aorta: consider extended repair, e.g. frozen elephant trunk (Class IIb)
- Root partly dissected, leaflets normal: resuspend the valve (Class I)
- Root destroyed, root aneurysm or genetic aortic disease: valved conduit root replacement (Class I)
- Valve-sparing root repair in selected patients by experienced surgeons (Class IIb)
13Action Post-Operative Care and Follow-Up
ICU care. Heart rate and BP control, then long-term oral beta-blocker unless contraindicated.
- Watch for bleeding, stroke, spinal cord ischaemia, kidney injury and persistent malperfusion
- Imaging: before discharge (CT; TTE after root surgery); then CT and TTE within 6 months, CT at 12 months, then yearly if stable; every 2 years after 5 years without complications
- Add ACE inhibitor or ARB as needed for BP control (not in pregnancy)
- All: multigenerational family history; aortic imaging for first-degree relatives. Age under 60, family history of aortic disease, aneurysms elsewhere or syndromic features: genetic testing and counselling
14Outcome Survived to Discharge: Lifelong Surveillance
Lifelong BP control and aortic imaging; residual distal dissection needs follow-up.
If No- Path rejoins step 10Shared downstream outcome
If No15Outcome Not Type A: Use the Matching Pathway
Type B: use the Type B aortic dissection pathway. Non-A non-B (arch): aortic team. No dissection: look for other causes.
Guideline Source
EACTS/STS Guidelines for Diagnosing and Treating Acute and Chronic Syndromes of the Aortic Organ (Czerny et al., 2024)
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- No doses given: use local protocol and product information. Nicardipine and IV diltiazem are not on the ARTG.
- Adults only. Pregnancy needs obstetric and aortic team care.
- Uncomplicated type A intramural haematoma with increased operative risk and no high-risk imaging features: the aortic team may choose medical therapy with serial imaging in an expert centre (Class IIb).
- Type B and non-A non-B dissection: see the Type B and acute aortic dissection pathways.
- Surgical technique depends on anatomy and surgeon experience.
- Does not cover chronic dissection or redo aortic surgery.
Contraindicated Populations
chronic_dissectionprior_aortic_surgery_complexchildren
Applicable Regions
EUUSGlobal
AU: Many hospitals have no cardiac surgery: call the cardiac surgical centre and retrieval service at diagnosis. Nicardipine and IV diltiazem are not on the ARTG; IV verapamil is the non-dihydropyridine option.
EU: EACTS/STS 2024 and ESC 2024 PAAD guidelines.
US: STS co-endorsed; 2022 ACC/AHA aortic guideline also applies.
Version 2Next review: 2027-09-30
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Related Resources
Frequently Asked Questions
What is the Acute Type A Aortic Dissection Management (EACTS/STS 2024)?
The Acute Type A Aortic Dissection Management (EACTS/STS 2024) is a emergency clinical algorithm for Cardiothoracic Surgery. It provides a structured decision tree to guide clinical decision-making, based on EACTS/STS Guidelines for Diagnosing and Treating Acute and Chronic Syndromes of the Aortic Organ (Czerny et al., 2024).
What guideline is the Acute Type A Aortic Dissection Management (EACTS/STS 2024) based on?
This algorithm is based on EACTS/STS Guidelines for Diagnosing and Treating Acute and Chronic Syndromes of the Aortic Organ (Czerny et al., 2024) (DOI: 10.1016/j.athoracsur.2024.01.021).
What are the limitations of the Acute Type A Aortic Dissection Management (EACTS/STS 2024)?
Known limitations include: No doses given: use local protocol and product information. Nicardipine and IV diltiazem are not on the ARTG.; Adults only. Pregnancy needs obstetric and aortic team care.; Uncomplicated type A intramural haematoma with increased operative risk and no high-risk imaging features: the aortic team may choose medical therapy with serial imaging in an expert centre (Class IIb).; Type B and non-A non-B dissection: see the Type B and acute aortic dissection pathways.; Surgical technique depends on anatomy and surgeon experience.; Does not cover chronic dissection or redo aortic surgery.. Individual patient factors may require deviation from these recommendations.
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