Written by Megan Hilbert
Early identification and treatment of thoracic aortic dissection is paramount to patient survival and good clinical outcomes. Here’s what you need to know.
Why does this matter?
Updated guidelines help dictate the standard-of-care. It is important to provide appropriate clinical care in patients with aortic pathology given its high morbidity and mortality. This guideline focuses on management. For clinical presentation, see this JF post.
Here to be your guide
The American Association for Thoracic Surgery (AATS) and the Society for Thoracic Surgery (STS) gathered to review relevant literature and were able to publish updated recommendations for management of both acute type A aortic dissection (ATAAD) and TBAD (type B aortic dissection). All of these recommendations possess at least moderate strength of evidence.
In the management of type A dissections, initial stabilization should include beta blockers and pain medication. Beta blockers in particular are associated with improved survival in those who undergo operative repair, OR 0.47 (95%CI 0.25-0.90, P=0.02). Those who undergo operative repair are also shown to have both decreased 48-hour (4.4%) and in-hospital mortality (19.7%) compared to those who are medically managed (23.7% and 57.1%, respectively). As such, they recommend transfer to a comprehensive aortic center when cardiac surgery is not available. High-volume centers are associated with a 7.2% absolute risk reduction (95%CI 4.1%-10.3%) for operative mortality, “despite delays due to interhospital transfer.”
In the management of TBAD, the first step involves evaluating for complicated disease: increased diameter of descending thoracic aorta/proximal dissection origination and organ malperfusion. In those without either of the above, optimal medical therapy with alpha- and beta-blockers (i.e. labetalol) is recommended. For those with evidence of malperfusion or complicated disease, thoracic endovascular aortic repair (TEVAR) is indicated (no matter if symptoms are hyperacute, acute, or subacute). TEVAR as compared to open surgical repair has been associated with lower 30-day, in-hospital: 9.1% vs 14.7%; OR 0.54 (95% CI 0.43-0.68, P<0.001) and 5-year mortality: OR 0.46 (95%CI 0.24-0.86; P=0.02).
Management of Thoracic Aortic Dissection. JAMA. 2023 Mar 7;329(9):756-757. doi: 10.1001/jama.2023.0265.