Complicated Acute Type B Aortic Dissection When Anti-Impulse Therapy Has Not Achieved Blood Pressure and Heart Rate Targets
Clinical scenario
Acute aortic dissection not involving the ascending aorta (Stanford type B) — that is, all dissections that do not involve the ascending aorta, including those involving the aortic arch that spare the ascending aorta — complicated by rupture, branch artery occlusion or malperfusion, extension of the dissection, aortic enlargement, intractable pain, or uncontrolled hypertension. Patients with these complications have an increased risk of morbidity and death, and urgent or emergency intervention may be required.
Previous step — and why it was insufficient
Initial management with prompt anti-impulse therapy (intravenous beta-blocker, vasodilator, or non-dihydropyridine calcium channel blocker with invasive blood pressure monitoring in an ICU setting) aims for a systolic blood pressure below 120 mm Hg and a heart rate of 60 to 80 bpm. When those haemodynamic targets are not achieved, or when life-threatening complications such as rupture, malperfusion, or uncontrolled hypertension are present, escalation to intervention is indicated.
Intervention approach (partial — full protocol via the link below)
When anatomy is suitable, an endovascular approach is preferred over open surgical repair; the exact technique and whether additional procedures targeting vascular complications are required depends on the nature of the complication present. The complete stepwise clinical algorithm is in the structured protocol.
Full regimen, sequencing, anatomical criteria, and decision points are available via the link below.
References
- DOI: 10.1161/CIR.0000000000001106
- Type B: All dissections that do not involve the ascending aorta (including dissections that involve the aortic arch but spare the ascending aorta).
- In patients with acute type B aortic dissection and rupture or other complications, intervention is recommended.
- Patients presenting with complicated acute type B aortic dissection, or developing such features after initial presentation, have an increased risk of morbidity and death, and urgent or emergency intervention may be required.
- In patients with rupture, in the presence of suitable anatomy, endovascular stent grafting, rather than open surgical repair, is recommended.
- In patients with other complications, in the presence of suitable anatomy, the use of endovascular approaches, rather than open surgical repair, is reasonable.
- Fenestration may be required if TEVAR alone does not correct the malperfusion, and visceral or renal artery stenting may also be required.
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