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Acute type A aortic dissection — ABIM Board MCQ

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ModerateCardiovascularAcute type A aortic dissectionABIM Board

A 66-year-old man has abrupt tearing chest pain radiating to the back. Blood pressure is 188/94 mm Hg in the right arm and 154/82 mm Hg in the left arm. CT angiography shows an intimal flap beginning in the ascending aorta and extending to the proximal descending thoracic aorta. He has no pericardial effusion. Intravenous esmolol has been started. Which of the following is the most appropriate management?

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Correct answer: B — Emergent open surgical repair

The correct answer is B. Involvement of the ascending aorta defines an acute Stanford type A aortic dissection, which requires emergency surgical consultation and immediate open repair because of the risks of rupture, tamponade, acute aortic regurgitation, coronary compromise, and malperfusion. Absence of pericardial effusion does not make a type A dissection suitable for observation. Intravenous esmolol is appropriate initial anti-impulse therapy but is a bridge to surgery, not definitive treatment. Thoracic endovascular stent grafting is used primarily for complicated type B dissections and does not address the ascending aortic disease here. Thrombolysis and anticoagulation can worsen bleeding or rupture. Outpatient follow-up is unsafe.

Reference: Isselbacher EM, Preventza O, Black JH III, et al. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease, section 'Initial Surgical Considerations in Acute Type A Aortic Dissection.' 2022. https://professional.heart.org/-/media/PHD-Files-2/Science-News/2/2022/2022-Aortic-Disease-Guideline-Slide-Set.pdf?sc_lang=en