Management – Overview

Immediate imaging is required, with CTA chest the gold standard to delineate the dissection. TEE provides rapid evaluation, especially of ascending dissection and complications. Initial management should not wait for confirmatory imaging if suspicion is high.

• Medical Management:
  • Anti-Impulse Medications: Additional medications may be used to control blood pressure in cases where beta-blockers alone are insufficient.
    
  • Blood Pressure Control: The reduction of blood pressure is crucial to minimize shear forces on the aortic wall and prevent further dissection
  • Pain Management: Acute aortic aneurysm dissection is associated with severe pain.

• Surgical Intervention:
  
  • Type A Dissection: Type A dissections involving the ascending aorta, aortic arch, or proximal descending aorta typically require emergent surgical intervention.
    
  • Type B Dissection: Type B dissections involving the descending thoracic aorta are initially managed with medical therapy unless complications or malperfusion are present. In selected cases, endovascular repair with stent graft placement (thoracic endovascular aortic repair, or TEVAR) may be considered to seal the entry tear and promote false lumen thrombosis.

• Surveillance and Follow-up:
  • Long-term management includes regular surveillance and follow-up imaging studies to monitor the size and progression of the aortic aneurysm, identify complications, and guide further interventions if necessary.
    
  • Lifestyle modifications, including blood pressure control, smoking cessation, and regular exercise, are recommended to reduce the risk of disease progression and complications.
    

Therapeutic Goals

1. The priority pharmacotherapy goals include:
   • Minimize shear forces on dissected aorta by controlling heart rate and blood pressure
   • Alleviate severe pain and anxiety
   • Prevent further propagation of dissection
   • Avoid agents causing reflex tachycardia or inotropy
   • Facilitate smooth postoperative recovery after surgical repair