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Cardiothoracic SurgeryEmergency

Type B Aortic Dissection Management (ESC 2024, EACTS-endorsed)

Type B Aortic Dissection Management (ESC 2024, EACTS-endorsed): Acute type B aortic dissection (adult) → Confirm with CT angiography; check for shock fi...

Pathway Overview

20 steps

Algorithm Steps

20 total

  1. 01Start

    Acute type B aortic dissection (adult)

    Ascending aorta not involved (Stanford B, DeBakey III). Manage with an aortic team; transfer to an aortic centre.

  2. 02Action

    Confirm with CT angiography; check for shock first

    ECG-gated CT angiography, neck to pelvis. Unstable or CT not possible: TOE. Do not delay treatment for results.

    • Ascending aorta involved: type A dissection. Use the type A pathway (emergency surgery)
    • Arch involved, ascending aorta spared (non-A non-B): aortic team now; repair may need arch surgery or a branched graft
    • Define entry tear, extent, branch vessels, malperfusion, aortic and false-lumen diameters
    • Measure BP in both arms and legs; treat the higher arm reading
  3. 03Warning

    Hypotension or shock: no beta-blocker or vasodilator

    SBP <90 mmHg or shock in type B dissection usually means rupture. Resuscitate, call the aortic team now and go to emergency repair (complicated step).

    • Do not give anti-impulse drugs while shocked
    • Rupture on CT: emergency TEVAR, or open repair if TEVAR not suitable
    • Tamponade or new aortic regurgitation: suspect ascending involvement (type A); use the type A pathway
  4. 04Warning

    Before treatment: malperfusion, pregnancy, heritable aortic disease

    These change BP targets, drugs and the type of repair.

    • Malperfusion or spinal cord ischaemia: do not drive BP too low; keep a higher MAP
    • Pregnancy: aortic and obstetric team; no ACE inhibitor or ARB
    • Marfan, Loeys-Dietz, vascular Ehlers-Danlos (known or suspected): open repair preferred; TEVAR only in emergency or as bridge
  5. 05Action

    Not shocked: anti-impulse therapy and analgesia

    Target SBP <120 mmHg and HR <=60 bpm, or the lowest BP that keeps organ perfusion. IV opioid, titrated to pain.

    • IV beta-blocker first: labetalol or esmolol
    • Beta-blocker contraindicated: IV verapamil (IV diltiazem where available). Not in AV block, bradycardia or heart failure: get ICU advice
    • SBP still at or above target after rate control: add IV vasodilator (e.g. glyceryl trinitrate). Never before rate control
    • ICU: arterial line, continuous ECG, urine output. Oral therapy after 24 h when on target and gut working
  6. 06Decision

    Complicated type B dissection?

    Complicated = any of: rupture (contained or free), malperfusion (mesenteric, renal, limb, spinal cord), extension or rapid enlargement on repeat imaging, refractory pain >12 h, or hypertension despite more than 3 drug classes.

  7. If Yes
    1. Complicated
    2. 07Action

      Complicated: emergency repair by the aortic team

      Emergency intervention is recommended. Continue anti-impulse therapy; accept a higher BP if malperfusion.

      • TEVAR is first-line when anatomy is suitable
      • Known or suspected heritable aortic disease: open repair preferred
      • Rupture with shock: resuscitate and go straight to repair
    3. 08Decision

      Suitable for TEVAR and no heritable aortic disease?

      Suitable = adequate proximal and distal landing zones and iliofemoral access.

    4. If Yes
      1. Suitable
      2. 09Action

        Suitable: TEVAR to cover the primary entry tear

        Aim: restore true-lumen flow, relieve malperfusion, promote false-lumen thrombosis.

        • Planned left subclavian coverage: revascularise the left subclavian artery (before TEVAR when time allows)
        • High spinal cord risk (long coverage, prior AAA repair): MAP support; consider CSF drain
        • Malperfusion persists: branch stenting, fenestration or bypass
        • Emergencies after TEVAR: new leg weakness (raise MAP; CSF drain); retrograde type A dissection (open surgery)
      3. 10Action

        All patients: lifelong BP control and risk factors

        Antihypertensive therapy for all patients with type B dissection.

        • SBP target 120-129 mmHg if tolerated (ESC 2024); ACC/AHA: <130/80 mmHg
        • Pregnancy or planning pregnancy: no ACE inhibitor or ARB
        • Stop smoking; avoid cocaine and other stimulants; lipid management
        • Young, family history or syndromic features: genetic assessment in an aortic centre
      4. 11Action

        Lifelong imaging: CT or MRI on a fixed schedule

        Use MRI where possible in young patients to reduce radiation, and when frequent scans are needed after the first year.

        • Medical therapy: 1, 3, 6 and 12 months after onset, then yearly if stable
        • After TEVAR: 1, 6 and 12 months, then yearly to year 5. Abnormal findings: CT every 3-6 months
        • After open repair: CT and echo within 6 months, CT at 12 months, then yearly
        • No complications for 5 years after repair: CT every 2 years
      5. 12Decision

        Surveillance imaging: progression?

        Check at each scan and visit. Progression = new symptoms, malperfusion, rapid growth or diameter >=55 mm.

      6. If Yes
        1. Progression
        2. 13Action

          Progression: refer to the aortic team for repair

          Up to half of patients develop aneurysmal change. Chronic dissection: open repair first-line if low risk or heritable disease; TEVAR for other eligible patients.

          • New symptoms, malperfusion or rupture: emergency repair
          • Descending aorta >=60 mm and reasonable surgical risk: repair recommended
          • Descending aorta >=55 mm and low procedural risk: consider repair
          • Heritable aortic disease: lower thresholds; open repair preferred
        3. 14Outcome

          After repair or aortic-team review: lifelong BP control and surveillance

          Imaging for life. After TEVAR: 1, 6 and 12 months, then yearly. After open repair: CT and echo within 6 months, CT at 12 months, then yearly.

        If No
        1. Stable
        2. 15Outcome

          Stable: continue medical therapy and lifelong surveillance

          Keep imaging for life; the distal false lumen often stays patent.

      If No
      1. Not suitable or heritable disease
      2. 16Action

        Not suitable for TEVAR or heritable disease: open repair

        Open graft replacement via left thoracotomy in an aortic centre, with spinal cord protection.

        • Heritable aortic disease: open repair preferred
        • Heritable disease with rupture and open repair not possible: TEVAR as a bridge
        • Alternative: frozen elephant trunk repair (EACTS/STS 2024)
      3. Path rejoins step 10Shared downstream outcome
    If No
    1. Uncomplicated
    2. 17Action

      Uncomplicated: optimal medical therapy in ICU

      Medical therapy is the initial treatment. Continue anti-impulse therapy and analgesia.

      • Reassess every day: pain, BP, pulses, urine output, lactate, neurology
      • New pain, malperfusion or growth on repeat CT: now complicated. Emergency repair
      • Oral beta-blocker based therapy when on target
    3. 18Decision

      High-risk features on CT or clinical course?

      Any of: aortic diameter >40 mm, false lumen >20-22 mm, entry tear >10 mm or on the inner curve, growth >5 mm on serial imaging, partial false-lumen thrombosis, haemorrhagic pleural effusion, radiological malperfusion, readmission or recurrent pain.

    4. If Yes
      1. High-risk
      2. 19Action

        High-risk uncomplicated: consider TEVAR at 14-90 days

        Subacute-phase TEVAR to prevent aortic complications, if anatomy is suitable and life expectancy >5 years.

        • Heritable aortic disease: no pre-emptive TEVAR; aortic team decides
        • Not suitable for TEVAR: medical therapy with closer surveillance
        • TEVAR done: follow the TEVAR step (left subclavian, spinal cord protection)
      3. Path rejoins step 10Shared downstream outcome
      If No
      1. No high-risk features
      2. 20Action

        No high-risk features: medical therapy and standard surveillance

        Continue optimal medical therapy. Recheck for complications and high-risk features on each scan.

      3. Path rejoins step 10Shared downstream outcome

Guideline Source

2024 ESC Guidelines for the management of peripheral arterial and aortic diseases (Mazzolai et al., Eur Heart J 2024;45:3538-3700), endorsed by EACTS; section 9.3.1.4 type B aortic dissection

DOI: 10.1093/eurheartj/ehae179View Guideline

Clinical Safety Information

Clinical Decision Support — Not a Substitute for Clinical Judgment

Individual patient factors may require deviation from these recommendations.

Known Limitations

  • Adults with acute type B dissection only; not for intramural haematoma or penetrating ulcer. TEVAR versus open repair, and repair timing, are aortic-team decisions.
  • No specific advice for cocaine- or methamphetamine-associated dissection: ESC 2024 and ACC/AHA 2022 give none. Get specialist advice before beta-blockade.
  • Pre-emptive TEVAR for high-risk uncomplicated dissection rests on limited trial data (INSTEAD-XL, ADSORB); high-risk definitions differ between guidelines.
  • Follows ESC 2024. EACTS/STS 2024 differs: acute SBP 100-120 mmHg and HR 60-80 bpm; repair of chronic dissection at >=55 mm (Class I).
  • Surveillance follows the ESC 2024 schedule; aortic centres may adapt it.
  • Medical therapy success depends on long-term adherence.

Contraindicated Populations

Type A dissection (ascending aorta involved): use the type A pathwayChildrenPregnancy: aortic and obstetric teamHeritable thoracic aortic disease (Marfan, Loeys-Dietz, vascular Ehlers-Danlos): open repair preferred

Applicable Regions

USEUAU

AU: No IV diltiazem on the ARTG: use IV verapamil when a beta-blocker is contraindicated. Vasodilator example is glyceryl trinitrate (available in Australia); otherwise follow the local vasodilator protocol.

EU: ESC 2024 (endorsed by EACTS): acute HR <=60 bpm with SBP <120 mmHg; long-term SBP 120-129 mmHg if tolerated. EACTS/STS 2024: acute SBP 100-120 mmHg with HR 60-80 bpm.

US: ACC/AHA 2022: acute HR target 60-80 bpm with SBP <120 mmHg; long-term BP <130/80 mmHg.

Version 2Next review: 2027-09-30

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Frequently Asked Questions

What is the Type B Aortic Dissection Management (ESC 2024, EACTS-endorsed)?

The Type B Aortic Dissection Management (ESC 2024, EACTS-endorsed) is a emergency clinical algorithm for Cardiothoracic Surgery. It provides a structured decision tree to guide clinical decision-making, based on 2024 ESC Guidelines for the management of peripheral arterial and aortic diseases (Mazzolai et al., Eur Heart J 2024;45:3538-3700), endorsed by EACTS; section 9.3.1.4 type B aortic dissection.

What guideline is the Type B Aortic Dissection Management (ESC 2024, EACTS-endorsed) based on?

This algorithm is based on 2024 ESC Guidelines for the management of peripheral arterial and aortic diseases (Mazzolai et al., Eur Heart J 2024;45:3538-3700), endorsed by EACTS; section 9.3.1.4 type B aortic dissection (DOI: 10.1093/eurheartj/ehae179).

What are the limitations of the Type B Aortic Dissection Management (ESC 2024, EACTS-endorsed)?

Known limitations include: Adults with acute type B dissection only; not for intramural haematoma or penetrating ulcer. TEVAR versus open repair, and repair timing, are aortic-team decisions.; No specific advice for cocaine- or methamphetamine-associated dissection: ESC 2024 and ACC/AHA 2022 give none. Get specialist advice before beta-blockade.; Pre-emptive TEVAR for high-risk uncomplicated dissection rests on limited trial data (INSTEAD-XL, ADSORB); high-risk definitions differ between guidelines.; Follows ESC 2024. EACTS/STS 2024 differs: acute SBP 100-120 mmHg and HR 60-80 bpm; repair of chronic dissection at >=55 mm (Class I).; Surveillance follows the ESC 2024 schedule; aortic centres may adapt it.; Medical therapy success depends on long-term adherence.. Individual patient factors may require deviation from these recommendations.

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