Optimal management of acute aortic dissection

Abstract

Acute aortic syndrome (AAS) encompasses a group of life-threatening aortic disorders that are increasing in prevalence. It classically presents with abrupt-onset chest pain that is of maximum intensity at onset. The syndrome requires prompt recognition and efficient treatment to optimize outcome. Contrast-enhanced CT is most commonly used as the definitive diagnostic imaging modality. Patients must be expeditiously transferred to institutions with case experience and medical, surgical, and endovascular expertise. Stanford type A dissections involve the ascending aorta and require emergent surgical consideration, unless underlying comorbidities make surgical risk prohibitive. Patients with Stanford type B, or descending, aortic dissection are less prone to rupture, shock, and cardiac complications. These patients are initially medically managed with targeted blood pressure and heart rate control. Surgical management is reserved for patients with intractable or recurrent pain, aortic expansion, end-organ ischemia, or progression of dissection. The feasibility of endovascular treatment is established, and its role in management continues to expand. Long-term follow-up with medical treatment and serial imaging of AAS patients is critical. Future directions in the diagnosis and treatment of AAS include using biomarkers to aid in diagnosis and prognosis, enhanced imaging with better resolution and reduced radiation exposure, and definition of the role of endovascular methods in acute and chronic settings.