Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

INITIAL

hemodynamically unstable: suspected aortic dissection

1st line – advanced life support with hemodynamic support

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INITIAL
|
hemodynamically unstable: suspected aortic dissection
1st line – 

advanced life support with hemodynamic support

Local resuscitation protocols should be followed.

Supplemental oxygen and hemodynamic support with intravenous fluid resuscitation and judicious use of inotropes is recommended in cases of incipient renal failure and hypovolemic shock. See Acute kidney injury and Shock.

Consult a specialist for guidance on suitable vasoactive drug regimens.

ACUTE

confirmed aortic dissection

1st line – beta-blocker or nondihydropyridine calcium-channel blocker

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ACUTE
|
confirmed aortic dissection
1st line – 

beta-blocker or nondihydropyridine calcium-channel blocker

Intravenous beta-blockers are used to achieve a systolic blood pressure less than 120 mmHg or to lowest blood pressure that maintains adequate end-organ perfusion and an appropriate target heart rate.[4]

Recommendations for target heart rate vary and local protocols should be followed; the American College of Cardiology/American Heart Association recommend a target heart rate of 60 to 80 bpm; the Society of Thoracic Surgeons/American Association for Thoracic Surgery recommend maintaining a heart rate of <70 bpm; the European Society of Cardiology recommends a heart rate of <60 bpm as the target for medical therapy.[6][14][4]​​​

In patients with contraindications (e.g., acute aortic regurgitation, heart block, or bradycardia), or intolerance to beta-blockers, initial management with an intravenous nondihydropyridine calcium-channel blocker (e.g., diltiazem) is reasonable for heart rate control.[4]​ Invasive monitoring of BP with an arterial line in an ICU setting is recommended to decrease aortic wall stress.[4]

Primary options

labetalol: 1-5 mg/min intravenous infusion

More

OR

esmolol: 500 micrograms/kg intravenously initially, followed by 50 micrograms/kg/min for 4 min, may repeat loading dose and increase infusion up to 200 micrograms/kg/min if necessary

More

OR

metoprolol tartrate: 5 mg intravenously every 5-10 minutes, maximum 15 mg/total dose

Secondary options

diltiazem: 0.25 mg/kg intravenously initially (may give another dose of 0.35 mg/kg after 15 minutes), followed by 5-15 mg/hour infusion for <24 hours

Plus – opioid analgesia

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ACUTE
|
confirmed aortic dissection
Plus – 

opioid analgesia

Treatment recommended for ALL patients in selected patient group

Pain control is an important first-line therapy to reduce sympathetic tone and facilitate hemodynamic stability.[10][14] It should be noted that morphine causes vasodilation and reduces the heart rate by increasing vagal tone.

Primary options

morphine sulfate: 2-5 mg intravenously every 5-30 minutes as needed

Plus – vasodilator

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ACUTE
|
confirmed aortic dissection
|
beta-blocker or calcium-channel blocker insufficient
Plus – 

vasodilator

Treatment recommended for ALL patients in selected patient group

If first-line treatment with beta-blockers (or nondihydropyridine calcium-channel blockers in patients with contraindications or intolerance to beta-blockers) and analgesia fail to achieve a systolic blood pressure less than 120 mmHg and an appropriate target heart rate, then intravenous antihypertensive vasodilator therapy (such as nitroprusside) should be added.[14][4]

Primary options

nitroprusside: 0.3 to 0.5 micrograms/kg/min intravenously initially, increase by 0.5 micrograms/kg/min increments; maximum 10 micrograms/kg/min

Plus – open surgery or endovascular stent-graft repair

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ACUTE
|
confirmed aortic dissection
|
type A
Plus – 

open surgery or endovascular stent-graft repair

Treatment recommended for ALL patients in selected patient group

Type A dissection involves the ascending aorta with or without involvement of the arch and descending aorta. In patients presenting with suspected or confirmed acute type A aortic dissection, emergency surgical consultation and evaluation with immediate surgical intervention is recommended, due to the high risk of associated life-threatening complications.[4]​ The mortality rate of medical management alone for acute type A aortic dissection is two to three times that of surgical intervention.[38]​ In patients who are stable enough, transfer from a low- to high-volume aortic center is reasonable in order to improve survival.[4]

Depending on the extent of retrograde extension, the aortic valve may or may not need to be repaired or replaced.[10] This is to prevent cardiac tamponade or fatal exsanguination from aortic rupture.

Therapeutic options include: open aortic arch replacement; transposition of supra-aortic branches with subsequent endovascular repair; total endovascular repair; or the frozen elephant trunk repair technique, which combines open repair of the proximal aorta under deep hypothermic circulatory arrest, together with placement of thoracic stent grafts into the distal aortic arch and upper descending thoracic aorta.[34] 

In patients with renal, mesenteric, or lower extremity malperfusion, immediate operative repair of the ascending aorta is recommended.[4]​ In patients presenting with clinically significant mesenteric (e.g., celiac, superior mesenteric) malperfusion, immediate mesenteric revascularization via endovascular or open surgical intervention before ascending aortic repair is also reasonable.[4]​ Evidence of mesenteric malperfusion includes abdominal pain, bowel ischemia, lactic acidosis, elevation of liver function test results.[4]

One meta-analysis of comparator observational studies reported lower stroke and mortality rates, but higher spinal cord ischemia events, with the frozen elephant trunk technique compared with conventional aortic arch surgery.[43] Longer term follow-up is necessary.[44]

Plus – endovascular stent-graft repair or open surgery

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ACUTE
|
confirmed aortic dissection
|
type B with complications (rupture, visceral/extremity ischemia, expansion, or persistent pain)
Plus – 

endovascular stent-graft repair or open surgery

Treatment recommended for ALL patients in selected patient group

Type B dissection involves only the descending thoracic aorta (distal to the left subclavian artery) and/or abdominal aorta.

Urgent surgical or endovascular intervention is required if type B dissection is complicated by rupture, visceral or extremity ischemia, aneurysmal expansion, or persistent pain.[4]​

For complicated type B dissections, the goal of open surgery is to resect/cover the entry tear and re-establish flow into compromised branch vessels. Although both open and endovascular therapies are acceptable options, the endovascular approach - including fenestration and stenting - is gaining preference over the open technique for patients presenting with complications.[10][45][46][47][48]

American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend endovascular stent grafting rather than open surgical repair in patients with acute type B aortic dissection with rupture, in the presence of suitable anatomy.[4]​ The ACC/AHA note that an endovascular approach, rather than open surgical repair, is also reasonable in patients with other complications (e.g., branch artery occlusion and malperfusion, extension of dissection, aortic enlargement, intractable pain, or uncontrolled hypertension).[4]​ The Society of Thoracic Surgeons/American Association for Thoracic Surgery (STS/AATS) state that TEVAR is indicated in patients with complicated hyperacute, acute, or subacute type B dissection and favorable anatomy for TEVAR.[6] However, open surgical repair is reasonable over TEVAR as a more durable treatment in patients with connective tissue disorders who have type B dissection with progression of disease despite optimal medical therapy.[6]

Consider – endovascular stent-graft repair

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ACUTE
|
confirmed aortic dissection
|
type B uncomplicated
Consider – 

endovascular stent-graft repair

Treatment recommended for SOME patients in selected patient group

Patients with uncomplicated type B aortic dissection (i.e., without end-organ malperfusion) are usually managed medically with blood pressure and pain control during the acute phase (less than 14 days).[24][10][14][34]​ The American College of Cardiology/American Heart Association and the Society of Thoracic Surgeons/American Association for Thoracic Surgery state that optimal medical therapy remains the recommended treatment for patients with uncomplicated type B dissection.[6] 

Thoracic endovascular aortic repair (TEVAR) is increasingly performed in patients with uncomplicated dissections in the subacute phase (14 days to 6 weeks) to promote false lumen thrombosis and prevent aneurysmal degeneration. However, there is considerable heterogeneity of published data; results from meta-analyses evaluating TEVAR in patients with type B aortic dissection should be interpreted with caution.

One meta-analysis found no evidence for survival benefit at 1 year for patients with acute uncomplicated type B aortic dissection (TBAD) treated with TEVAR compared with those receiving best medical therapy.[52] Another meta-analysis found that TEVAR did not prevent aneurysmal degeneration in patients treated for acute or chronic (including complicated) TBAD, noting that long-term data are lacking.[53] Results from one meta-analysis of a mixed patient population (complicated/uncomplicated, acute/subacute TBAD) and one randomized study of patients with stable TBAD, respectively, suggest that aneurysm-specific outcomes may be favorable over the longer term following TEVAR.[54][55]​ Larger trials with longer-term data are still required.[4]

There may be some benefit to early endovascular intervention in patients with uncomplicated acute type B aortic dissection with refractory pain and hypertension.[56] TEVAR in the subacute phase of type B dissection may be associated with a lower risk of complications, particularly retrograde type A dissection.[57]

Consider – open surgery or endovascular stent-graft repair

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ACUTE
|
confirmed aortic dissection
|
chronic (all types)
Consider – 

open surgery or endovascular stent-graft repair

Treatment recommended for SOME patients in selected patient group

Patients with chronic aortic dissection may need open surgical repair or endovascular therapy (TEVAR) in their lifetime; some will not have open surgical repair or TEVAR previously while others might have one of the procedures for the second time.

Indications for surgery in uncomplicated chronic aortic dissections depend on aortic diameter, pathogenesis, and the presence of symptoms. Asymptomatic chronic thoracic and thoracoabdominal aortic dissections with a maximal orthogonal aortic diameter of 6.0 cm in patients without connective tissue disease warrant repair.​[24][10][59] Rapid growth rate >0.5 cm per year also may be an indication for repair.[24] Patients with connective tissue diseases and those with a family history warrant more careful consideration and may warrant earlier intervention (diameter of 5.0–5.5 cm).[24][60][61]

The use of thoracic endovascular aortic repair (TEVAR) has been increasingly used for thoracic and thoracoabdominal aortic aneurysm repair occuring after aortic dissection because of the low acute risk compared with open repair and the potential to reduce aortic mortality and reoperations compared with medical therapy.[24] However, TEVAR faces anatomic and morphological limitations to successfully treating this disease, particularly in the chronic stage.[24][62][63][64][65] TEVAR may be a viable rescue option for patients with type A dissection who are not eligible for open surgical repair.[66]

The goals of TEVAR therapy are to: cover the entry tear; treat or prevent impending rupture; re-establish organ perfusion; restore flow in the true lumen; and induce the false lumen thrombosis.

One Cochrane review noted a lack of randomized controlled trials (RCTs) and controlled clinical trials investigating the effectiveness and safety of TEVAR compared to open surgical repair for patients with complicated chronic type B aortic dissection. The investigators were therefore unable to provide any evidence to inform decision-making on the optimal intervention for these patients.[67] In a retrospective analysis of 80 patients who underwent TEVAR for chronic type B aortic dissections, complete false lumen thrombosis was achieved in 52% and aneurysm diameter was stabilized or reduced in 65%. Five-year overall survival was 70%. 

In a prospective multicenter trial from China, TEVAR for chronic type B aortic dissection decreased the risk of aortic-related mortality compared with optimal medical therapy alone at 4 years, but failed to improve overall survival. The thoracic aorta diameter decreased significantly in the TEVAR group, but increased in the medical therapy group.[68] 

There currently are no longer-term data on the efficacy of TEVAR for chronic type B aortic dissection.

ONGOING

after hospital discharge

1st line – antihypertensive therapy

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ONGOING
|
after hospital discharge
1st line – 

antihypertensive therapy

No patient is considered cured. Blood pressure control is continued after discharge from the hospital.[58] Beta-blockers and ACE inhibitors are usually required, with additional antihypertensives such as diuretics or calcium-channel blockers used if necessary.[10][14]

At least 40% of patients will require combination treatment to control blood pressure.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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