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Thoracic aortic dissection

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Updated 2024 ESC guidelines for the evaluation and management of 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 European Society of Cardiology (ESC 2024), 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 ...
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Screening and diagnosis

Screening of family members, technical considerations: as per EACTS/STS 2024 guidelines, test family members by simpler, more cost-efficient Sanger sequencing of only the suspect genetic area.
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  • Screening of family members (indications)

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.
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Diagnostic investigations

Clinical assessment: as per ESC 2024 guidelines, use a multiparametric algorithm for ruling in or out acute aortic syndrome using the aortic dissection detection-risk score in patients presenting with clinical features compatible with possible acute aortic syndrome.
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  • ECG

  • D-dimer testing

  • Chest radiography

  • Aortic imaging

  • Echocardiography

  • Genetic testing

Medical management

General principles: as per ESC 2024 guidelines, consider guiding clinical management by the underlying gene/variant, when known, in patients with heritable thoracic aortic disease.
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  • Indications for nonoperative management (type B aortic dissection)

  • Indications for nonoperative management (type A aortic dissection)

  • Nonoperative management (choice of agents)

  • Initial hemodynamic and pain control

  • Management of hypertension (ACCF)

  • Management of hypertension

  • Management of dyslipidemia (ACCF)

  • Management of dyslipidemia

  • Management of diabetes

Nonpharmacologic interventions

Smoking cessation: as per ESC 2024 guidelines, advise cessation and abstinence from smoking of any kind in patients with aortic disease to reduce the risk of myocardial infarction and death.
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  • Smoking cessation (ACCF)

  • Physical activity

  • Dietary changes

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.
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  • Intraoperative organ protection (spinal cord)

Surgical interventions

Setting of care: as per ESC 2024 guidelines, consider transferring patients with acute type A aortic dissection from a low- to a high-volume aortic center with the presence of a multidisciplinary team to improve survival if transfer can be accomplished without significant delay in surgery.
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  • Timing of surgery

  • 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.
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  • Patients with aortic intramural hematoma (initial medical therapy)

  • Patients with aortic intramural hematoma (TEVAR)

  • Patients with aortic intramural hematoma (open repair)

  • Patients with aortic intramural hematoma (surveillance)

  • Patients with penetrating atherosclerotic ulcer (initial medical therapy)

  • Patients with penetrating atherosclerotic ulcer (TEVAR)

  • Patients with penetrating atherosclerotic ulcer (open repair)

  • Patients with penetrating atherosclerotic ulcer (surveillance)

  • Patients with infectious aortitis

  • Patients with chronic aortic dissection

  • Patients with stroke

Patient education

Genetic counseling: as per ESC 2024 guidelines, provide genetic counseling at an expert center and offer subsequent testing, if indicated, in patients with thoracic aortic dissection and risk factors for heritable thoracic aortic disease.
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  • General counseling

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.
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Consider transferring patients with complicated acute type A aortic dissection to a comprehensive aortic center.
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  • Clinical follow-up

  • Imaging follow-up

  • Cardiac rehabilitation