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Thoracic aortic dissection

Key sources
The following summarized guidelines for the evaluation and management of thoracic aortic dissection are prepared by our editorial team based on guidelines from the Society of Thoracic Surgeons (STS/AATS 2022), the American Heart Association (AHA/ACC 2022), the American Association for Thoracic Surgery (AATS 2021), the European Society for Vascular Surgery (ESVS/EACTS 2019), the American College of Emergency Physicians (ACEP 2015), the European Society of Cardiology (ESC 2014), and the Society for Cardiovascular Angiography and Interventions (SCAI/STS/SVM/AATS/SCA/AHA/ACR/ACC/ASA/SIR 2010).
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Guidelines

1.Screening and diagnosis

Screening of first-degree relatives: evaluate first-degree relatives (siblings and parents) of a patient with thoracic aortic aneurysm and dissection to identify a familial form in which relatives all have a 50% chance of carrying the family mutation/disease.
B
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2.Diagnostic investigations

General principles: ensure a stepwise approach to the evaluation and treatment of patients with acute/subacute uncomplicated type B aortic dissection, including identification of the primary entry tear site location, defining the proximity and distance of the dissection to the left subclavian artery, calibration of the maximum orthogonal aortic diameter, and confirmation of the lack of any organ malperfusion or other indications of complicated disease.
B

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  • Clinical assessment

  • ECG

  • D-dimer testing

  • Chest radiography

  • Aortic imaging

  • Genetic testing

3.Medical management

Indications for nonoperative management, general principles, ESC: initiate medical therapy including pain relief and BP control in all patients with aortic dissection.
B

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  • Indications for nonoperative management (type B aortic dissection)

  • Acute HR and BP control

  • Management of hypertension

  • Management of dyslipidemia

4.Nonpharmacologic interventions

Smoking cessation: advise smoking cessation and avoidance of exposure to environmental tobacco smoke at work and home. Provide follow-up, referral to special programs, and/or pharmacotherapy (including nicotine replacement, buproprion, or varenicline), and adopt a stepwise strategy aimed at smoking cessation (the 5 As are Ask, Advise, Assess, Assist, and Arrange).
B

5.Perioperative care

Perioperative organ protection, brain, AHA/ACC: consider performing axillary cannulation over femoral cannulation, when feasible, to reduce the risk of stroke or retrograde malperfusion in patients with acute type A aortic dissection undergoing surgical repair.
C
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  • Perioperative organ protection (spinal cord)

6.Surgical interventions

Timing of surgery
As per ACC 2022 guidelines:
Obtain emergency surgical consultation and evaluation and perform an immediate surgical intervention in patients presenting with suspected or confirmed acute type A aortic dissection because of the high risk of associated life-threatening complications.
B
Consider transferring patients presenting with acute type A aortic dissection stable enough for transfer from a low- to a high-volume aortic center to improve survival.
C

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  • TEVAR (type B aortic dissection)

  • Open surgical repair (type A aortic dissection)

  • Open surgical repair (type B aortic dissection)

  • Hybrid open-endovascular repair

  • Aortic fenestration

  • Management of malperfusion

7.Specific circumstances

Pregnant patients: perform urgent aortic surgery with fetal monitoring in patients with acute type A aortic dissection during the first or second trimester of pregnancy.
B
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  • Patients with aortic intramural hematoma

  • Patients with infectious aortitis

  • Patients with stroke

  • Patients with chronic aortic dissection

8.Follow-up and surveillance

Serial clinical assessment: obtain close clinical follow-up after hospital discharge in patients presenting with acute type B aortic dissection.
B

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  • Serial imaging assessment

  • Cardiac rehabilitation