Treatment

• Stanford A dissection: immediate surgery.

• Stanford B dissection: treat conservatively (watchful waiting and ongoing medical therapy) unless complications occur. [4][23]

• Blood pressure control: essential in all patients to prevent progression of the dissection

• Supportive care

Avoid thrombolytic therapy in patients with suspected aortic dissection, e.g., for patients presenting with features of stroke or MI.

• Indications

  • All patients with Stanford A dissection [4]

  • Patients with Stanford B dissection who develop complications

• Procedure

  • Open surgery with the replacement of the dissection with a polyester graft implantation [4]

  • Endovascular treatment with aortic stent implantation (only in type B dissections and if the open operative risk is too high) [4]

Ascending aortic dissection is a surgical emergency!

Hypotensive patients

• Hemodynamic support: target MAP of 70 mm Hg or euvolemia [4]

  • IV fluids

  • Vasopressor support: if the patient remains hypotensive

    • Norepinephrine

    • Phenylephrine

    • Inotropes should be avoided as they can increase shear stress on the aortic wall through increased force of ventricular contraction.

• Identify and treat, if possible, any comorbidities that may be contributing to the hypotension

  • Severe aortic insufficiency

  • Cardiac tamponade

• Expedite operative management.

Avoid inotropes as they can worsen aortic wall stress.

• Control hypertension and heart rate: target SBP 100–120 mm Hg and HR ≤ 60 beats per minute

  • Start with an IV beta blocker: to avoid reflex tachycardia

    • Esmolol

    • Labetalol

  • Followed by vasodilator (e.g., IV sodium nitroprusside)

  • Contraindications to beta blockers: Start a calcium channel blocker.

    • Verapamil

    • Diltiazem

• Patients with dissection of the descending aorta who remain stable on IV treatment can be transitioned to oral medications and discharged with outpatient imaging surveillance.

Start beta blocker therapy before vasodilators to avoid reflex tachycardia!

Adequate treatment of pain and anxiety helps reduce sympathetic tone, which reduces blood pressure and heart rate, thereby lowering shear stress.

• Initiate pain management (e.g., morphine).

• Consider procedural sedation.

• Identify and treat any complications (e.g., mesenteric ischemia, acute kidney injury).