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Treatment of thoracic dissections and aneurysms

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

Authoring team

All patients with confirmed aortic dissection (or symptomatic high risk patients) should be referred to a regional cardiovascular unit for urgent diagnostic investigation and treatment (1).

Initial management of patients with suspected aortic dissection involves:

  • fluid resuscitation
  • monitoring heart rate, heart rhythm, blood pressure, urine output and respiratory functions
  • adequate pain relief
  • aggressive blood pressure control to reduce the force of left ventricular ejection
    • beta blockers are the preferred agents
    • target a heart rate around 60-80 beats/min and systolic blood pressure of 100-120 mm Hg
  • 12-lead ECG to exclude concurrent myocardial ischaemia (1)

Type A dissection

  • the International Registry of Acute Aortic Dissection have suggested that untreated proximal (Stanford type A or DeBakey type I or II) dissection is associated with a one week mortality of 50-91% (due to complications such as aortic rupture, stroke, visceral ischaemia, cardiac tamponade, and circulatory failure)
  • urgent surgical management is essential since drug treatment alone was associated with a mortality of nearly 20% by 24 hours and 30% by 48 hours
    • surgical approach is to replace the affected ascending aorta, with or without the aortic arch, with a prosthetic graft
    • an incompetent aortic valve is replaced when it is abnormal, for example in Marfan's disease, otherwise it is re-suspended (1)

Acute type B dissection

  • for uncomplicated acute type B dissection (without visceral or limb ischaemia, rupture, refractory pain, or uncontrollable hypertension) - medical management remains the gold standard
    • regulation of systolic blood pressure with the use of β blockers (first line agents) or non-dihydropyridine calcium channel blockers (for patients who do not tolerate beta blockers and in patients with chronic obstructive pulmonary disease)
  • for complicated acute type B dissection (defined by the presence of visceral or limb ischaemia, rupture, refractory pain, or uncontrollable hypertension) - endovascular repair using a stent graft
    • long term postoperative surveillance should be carried out in these patients
    • NICE state that this procedure "..is a suitable alternative to surgery in appropriately selected patients, provided that the normal arrangements are in place for consent, audit and clinical governance..." (2).

Chronic type B dissection

  • is a difficult condition to treat
  • can be managed conservatively but most patients ultimately develop complication which requires surgical intervention (e.g. - aneurysm which develops in 15% of chronic type B dissections)

Reference:

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