Lit Matters 3: Aortic Dissection: Surgery, Transfer, or Medical Management?

Acute aortic dissection management hinges on anatomy, malperfusion, and immediate hemodynamic control. Type A dissection is a surgical disease with transfer to a comprehensive aortic center often favored when feasible, while Type B dissection starts with anti-impulse therapy and escalates to TEVAR when features become complicated.

Type A and Type B Dissection

• Immediate anti-impulse therapy: Beta-blockade, blood pressure control, and aggressive pain treatment come first in both Type A and Type B dissection because shear stress reduction is the earliest lifesaving move.
• Type A surgical priority: Ascending aortic dissection is treated with urgent surgery, with medical therapy serving as stabilization rather than definitive care; medical management alone carries markedly higher in-hospital mortality.
• Comprehensive center transfer: When cardiac surgery is not available, transfer to a high-volume aortic center can improve outcomes even with transport delays, with an absolute mortality reduction of about 7%. We get into the transfer nuance in the episode.
• Complicated Type B markers: Type B dissection turns high risk when organ malperfusion appears or the anatomy is unfavorable, especially a greater-curvature distal arch tear or an enlarged descending aorta.
• Uncomplicated Type B approach: In uncomplicated Type B dissection, optimal medical therapy with alpha-beta blockade and impulse control remains first-line; early TEVAR has not shown a two-year mortality benefit here.
• TEVAR for complicated Type B: For hyperacute, acute, or subacute complicated Type B dissection, TEVAR is the preferred intervention and outperforms open repair on short-term mortality, with timing details still unsettled. We walk through that uncertainty in the chapter.