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Thoracic aortic dissection

Guidelines

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/EACTS 2024), the American Heart Association (AHA/ACC 2022), the Society of Thoracic Surgeons (STS/AATS 2022), the American Association for Thoracic Surgery (AATS 2021), the European Society for Vascular Surgery (ESVS/EACTS 2019), the ...
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Screening and diagnosis

Screening of family members, indications: as per ESC 2014 guidelines, 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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  • Screening of family members (technical considerations)

Classification and risk stratification

Risk assessment: as per EACTS/STS 2024 guidelines, use Ishimaru zones as a reporting standard for disease extent in patients with aortic dissection.
B
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Diagnostic investigations

General principles: as per AATS/STS 2022 guidelines, 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

Medical management

Indications for nonoperative management, type B aortic dissection: as per EACTS/STS 2024 guidelines, offer optimal medical therapy with close monitoring and follow-up for emerging high-risk features in patients with acute type B aortic dissection without high-risk features.
B

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  • Indications for nonoperative management (general principles)

  • Indications for nonoperative management (type A aortic dissection)

  • Acute HR and BP control

  • Management of hypertension

  • Management of dyslipidemia

Nonpharmacologic interventions

Smoking cessation: as per AATS/ACC/ACR/AHA/ASA/SCA/SCAI/SIR/STS/SVM 2010 guidelines, 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

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  • Physical activity

Perioperative care

Intraoperative organ protection, brain: as per EACTS/STS 2024 guidelines, consider performing antegrade systemic perfusion via axillary or direct aortic cannulation in patients with type A aortic dissection undergoing surgical repair.
C

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  • Intraoperative organ protection (spinal cord)

Surgical interventions

Timing of surgery
As per ACC/AHA 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 A aortic dissection)

  • 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 the aortic root

  • Management of the aortic arch

  • Management of malperfusion

Specific circumstances

Pregnant patients: as per EACTS/STS 2024 guidelines, offer Cesarean delivery in pregnant patients with a history of aortic dissection.
B
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  • Patients with aortic intramural hematoma (expectant management)

  • Patients with aortic intramural hematoma (indications for surgery)

  • Patients with aortic intramural hematoma (TEVAR)

  • Patients with aortic intramural hematoma (surveillance)

  • Patients with penetrating atherosclerotic ulcer

  • Patients with infectious aortitis

  • Patients with chronic aortic dissection

  • Patients with stroke

Follow-up and surveillance

Indications for referral
As per AATS 2021 guidelines:
Consider transferring patients with acute type A aortic dissection to a comprehensive aortic center, if cardiac surgery is not immediately available.
C
Consider transferring patients with complicated acute type A aortic dissection to a comprehensive aortic center.
C

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  • Clinical follow-up

  • Imaging follow-up

  • Cardiac rehabilitation