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)
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