Aortic Dissection: Management

Key points

• Stanford classification: type A = ascending aorta (about 2/3 of cases, needs surgery); type B = descending aorta, distal to the left subclavian origin (about 1/3, usually managed medically).
• DeBakey: type I originates in the ascending aorta and extends to at least the arch; type II is confined to the ascending aorta; type III originates in the descending aorta and extends distally.
• Initial medical therapy (both types): reduce aortic wall stress — give an IV beta-blocker first (labetalol or esmolol) to target heart rate under 60 and systolic BP 100-120 mmHg, before adding a vasodilator (avoid vasodilators alone, which cause reflex tachycardia).
• Type A → emergency surgery. Uncomplicated type B → medical management (BP/HR control, bed rest). Complicated type B (malperfusion, rupture, refractory pain/hypertension) → thoracic endovascular aortic repair (TEVAR).
• Complications — backward tear: aortic regurgitation, inferior MI (right coronary involvement), tamponade; forward tear: unequal arm pulses/BP, stroke, renal failure, mesenteric ischaemia. Best investigation = CT angiography of the chest (CXR may show a widened mediastinum but about 20% are normal; intimal calcium 10 mm or more from the outer aortic border suggests dissection).

Decision points in this pathway

• Stanford type A (ascending aorta)?
• Stanford type A or B?

The full step-by-step algorithm, including what to do at each branch, opens in the app for approved members.