Suspected Acute Type A Aortic Dissection
Patient with sudden severe chest/back pain, BP differential, widened mediastinum, or aortic regurgitation
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 → Immediate Stabilization → CTA Confirms Type A Dis...
Pathway Overview
14 steps
Algorithm Steps
14 total
01Start 02Action 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
03Decision 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)
04Decision 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
05Action 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
06Action 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
07Action 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
08Action 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
09Outcome Survived to Discharge
Long-term surveillance required
10Warning High Mortality Risk
30-day mortality 15-25% in experienced centers
11Action 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
- Path rejoins step 05Shared downstream outcome
12Action 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
13Action Not Type A
If type B or intramural hematoma
- Type B: Medical management unless complicated
- IMH: Treat similar to dissection type
- Consider alternative diagnoses
14Warning ⚠️ Watch for Tamponade
Pericardial effusion with dissection = impending rupture. Do NOT perform pericardiocentesis - proceed directly to OR
Guideline Source
EACTS/STS Guidelines for Diagnosing and Treating Acute and Chronic Syndromes of the Aortic Organ
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Does not address type B dissection (see separate algorithm)
- Requires immediate surgical consultation - do not delay for imaging optimization
- Institutional protocols may vary for cannulation strategy
- Specific surgical techniques depend on surgeon experience and anatomy
- Does not cover chronic dissection or prior aortic surgery
Contraindicated Populations
chronic_dissectionprior_aortic_surgery_complex
Applicable Regions
EUUSGlobal
EU: EACTS primary guidelines
US: STS co-endorsed, ACC/AHA 2022 also applicable
Version 1Next review: 2029-01-01
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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.
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 (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: Does not address type B dissection (see separate algorithm); Requires immediate surgical consultation - do not delay for imaging optimization; Institutional protocols may vary for cannulation strategy; Specific surgical techniques depend on surgeon experience and anatomy; Does not cover chronic dissection or prior aortic surgery. Individual patient factors may require deviation from these recommendations.
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