Current management of type B aortic dissection

Figures & data

Figure 1 Layers of aortic wall.

Figure 2 Aortic dissection. Actual specimen (A) and intravascular imaging (B) show both the true and false lumen.

Table 1 Characteristics of patients (N = 951) with acute aortic dissection – from the International Registry of Acute Aortic Dissection⁸

Risk factor	% of Patients Age < 40 years (N = 68)	% of Patients Age ≥ 40 years (N = 883)
Age, years	30.7	63.9
Type A dissection	68	65
Type B dissection	32	35
Male	76	67
Medical and social history
Hypertension*	34	72
Atherosclerosis*	1	30
Known aortic aneurysm	19	13
Bicuspid aortic valve* (N = 516)	9	1
Known aortic valve disease	10	8
Marfan syndrome*	50	2
Peripartum	3	0
Cocaine-related	0	0.6
Diabetes mellitus	0	4
Previous history of cardiac surgery
Aortic valve replacement*	12	5
CABG	0	6
Prior history of aortic dissection	7	6

Note: *Statistically different between the two groups.

Figure 3A Debakey classification.

Figure 3B Stanford classification of aortic dissection. Stanford type A includes dissections that involve the ascending aorta, arch, and descending thoracic aorta. Stanford type B includes dissections that originate in the descending (and thoracoabdominal) aorta, regardless of any retrograde involvement of the arch.

Figure 4 Computer tomography with enhanced contrast showing type B dissection.

Figure 5 Intravascular imaging of aortic dissection.

Table 2 Approach to acute aortic dissections (AAD) in the emergency department

1) Have a high index of suspicion for AAD

a) History:

i) Sudden onset, severe, sharp or tearing back pain, chest pain, shoulder pain, or abdominal pain

ii) Older than 60 years, history of hypertension, aortic dissection or aortic aneurysm (of family history of such), previous cardiac surgery, connective tissue disorder (Bicuspid aortic valve, Marfan syndrome, Ehler-Danlos syndrome, Loeys-Dietz syndrome), or peripartum

b) Physical examination:

(1) Pulse deficit, blood pressure differential in various extremities

(2) Neurological deficits

(3) Abdominal pain, flank pain

2) General measures:

a) Establish two large bore (>18gauge) IV’s

b) Administer supplemental oxygen by nasal cannula or nonrebreather mask

c) Put patient on cardiac monitor

d) Get an EKG, portable chest X-ray, place a Foley catheter

e) Obtain CBC, chemistry panel, coagulation panel, UA, CK, Troponin, d-dimer

f) Type and cross 10 units packed red blood cells (PRBC’s)

g) Set up an arterial line

3) Early cardiothoracic surgical consultation

4) Definitive imaging:

a) Computed tomography angiogram (CTA)

b) Transesophageal echocardiogram

c) Magnetic resonance angiogram (MRA)

d) Intravascular ultrasound

e) Aortography

5) Blood pressure, heart rate, and pain management

a) First line: β-blockers

i) Labetalol, bolus (15 mg) ± a drip (5 mg/hour),

b) If hypertension persists, add:

i) Nicardipine drip (starting dose: 5 mg/h)

c) If tachycardia persists, add:

i) Esmolol (loading 0.5 mg/kg over 2–5 min, followed by a drip of 10–20 μg/kg/min)

ii) Diltiazem drip (loading 0.25 mg/kg over 2–5 min, followed by a drip of 5mg/h)

d) Goals:

(1) Heart rate <60 beats/min

(2) Systolic blood pressure <100 mm Hg

e) Morphine (for pain relief)

6) Hemodynamically unstable patients

a) Tracheal intubation, mechanical ventilation

b) Blood pressure support with crystalloid and colloid (PRBC’s if rupture is suspected)

c) TEE at bedside in the Emergency Department or in the OR

d) Pericardiocentesis is not recommended (class III)

Table 3 Indications for endovascular or surgical intervention in patients with type B AAD

Persistent or recurrent pain despite adequate antiimpulsive and anti-hypertensive therapy (at least two parenteral agents at moderate to high dose) Acute expansion of the false lumen Periaortic or mediastinal hematoma (contained rupture) Visceral, renal or limb malperfusion syndrome

Neurological deficits (relative indication).

JanuzziJLIsselbacherEMFattoriRCharacterizing the young patient with aortic dissection: results from the International Registry of Aortic Dissection (IRAD)J Am Coll Cardiol200443665914975480

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