Aortic Dissection

Aortic dissection: intimal tear with blood entering the media, creating a false lumen. Stanford Type A: involves ascending aorta — surgical emergency (50% mortality untreated). Stanford Type B: descending aorta only — medical management (BP…

ESC Aortic Disease Guidelines / Stanford Classification

The pathway

1 · Recognise — think dissection

Tearing/ripping pain, sudden onset, maximal at onset, radiates to back/interscapular region
Pulse differentials (BP difference >20mmHg between arms)
Aortic regurgitation murmur
Neurological deficits (carotid involvement)
New LBBB or inferior ST elevation (coronary involvement — do NOT thrombolyse)

2 · Immediate stabilisation

2 large-bore IV cannulae
Morphine 5mg IV for pain
Call senior/cardiothoracic immediately
NBM
Group & save, cross-match 6 units
DO NOT give thrombolytics even if ECG looks like STEMI
Troponin will be elevated — does not change initial management

3 · Urgent imaging

CT aortogram (chest/abdomen/pelvis) with IV contrast: diagnostic — defines Stanford type, extent, branch vessel involvement, pericardial effusion, tamponade
If haemodynamically unstable: transoesophageal echo (TOE) in theatre
CXR: widened mediastinum (>8cm), pleural effusion, tracheal deviation

4 · BP & HR control

Target SBP 100–120mmHg AND HR <60bpm — reduces shear stress on dissection
IV labetalol: 20mg bolus, then 2mg/min infusion
Or IV esmolol infusion (shorter acting — better in operative setting)
If contraindication to beta-blocker: IV diltiazem
DO NOT allow SBP >140

5 · Type A — emergency surgery

Type A dissection: cardiothoracic surgery immediately
1-2% mortality per hour untreated
Transfer to cardiac surgical centre if not available locally
Do not delay for further investigations beyond CT

6 · Type B — medical management

Type B: IV antihypertensives, pain control, close monitoring (ICU)
Complicated Type B (malperfusion, rupture, uncontrolled pain): TEVAR (thoracic endovascular aortic repair) or open surgery
Uncomplicated Type B: medical management + surveillance CTA at 1, 3, 6, 12 months

Drugs

Drug	Dose	Route	Notes
Labetalol	20mg IV bolus then 2mg/min infusion	IV	First-line BP + HR control. Target SBP 100–120, HR <60.
Esmolol	500mcg/kg loading then 50–200mcg/kg/min	IV infusion	Short-acting beta-blocker — preferred in operative/unstable setting.
Morphine	5–10mg	IV slow	Pain control reduces sympathetic drive and further BP rise.

When to escalate

Type A dissection → cardiothoracic surgery IMMEDIATELY — 1-2% mortality per hour untreated,Haemodynamic instability → ITU resuscitation, prepare for emergency theatre,Neurological deficit or limb ischaemia → vascular/cardiothoracic emergency,Cardiac tamponade on imaging → pericardiocentesis as bridge to surgery,Complicated Type B → TEVAR or surgical centre transfer

Reference: ESC Guidelines on Aortic Diseases 2014 (updated 2022)

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