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Complicated Stanford type B aortic dissection with suspected mesenteric malperfusion — MRCEM SBA MCQ

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HardCardiovascular emergenciesComplicated Stanford type B aortic dissection with suspected mesenteric malperfusionMRCEM SBA

A 58-year-old woman presents to a district general hospital with abrupt, severe back pain. CT aortography shows a dissection confined to the aorta distal to the left subclavian artery. The superior mesenteric artery is supplied by a markedly narrowed true lumen. While awaiting a management plan, she develops increasing abdominal pain and her lactate rises from 1.5 to 4.2 mmol/L. Her abdomen is tender without guarding or rigidity. Blood pressure is 184/98 mmHg and heart rate is 112/min. She has received analgesia and has no contraindication to beta-blockade. What is the most appropriate initial treatment and disposition?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: A — Commence intravenous labetalol and arrange urgent specialist aortic transfer for assessment of endovascular intervention.

The dissection is Stanford type B because it is confined to the aorta distal to the left subclavian artery. The narrowed true lumen supplying the superior mesenteric artery, worsening abdominal pain and rising lactate together indicate visceral malperfusion. This makes the dissection *complicated*: blood pressure control alone is insufficient, and urgent specialist aortic assessment for possible endovascular intervention is required. Her hypertension and tachycardia warrant prompt anti-impulse treatment with intravenous labetalol while referral and appropriately monitored transfer are arranged; treatment should continue during transfer, with attention to organ perfusion. ([england.nhs.uk](https://www.england.nhs.uk/south/wp-content/uploads/sites/6/2024/02/South-England-Supra-regional-SOP-on-the-Acute-Management-of-Aortic-Dissections-v1.0-FINAL-1.pdf)) B offers appropriate medication and specialist discussion, but local medical management is a potential pathway for an **uncomplicated** type B dissection, not evolving malperfusion. C responds to threatened bowel, but the absence of peritonitis does not establish a need for local laparotomy ahead of assessment of the aortic cause. D selects the appropriate destination but omits initial beta-blockade despite marked tachycardia and no contraindication; a vasodilator may be considered if hypertension persists after beta-blockade. E describes an operative pathway for ascending-aortic involvement, which CT excludes. ([england.nhs.uk](https://www.england.nhs.uk/south/wp-content/uploads/sites/6/2024/02/South-England-Supra-regional-SOP-on-the-Acute-Management-of-Aortic-Dissections-v1.0-FINAL-1.pdf))

Reference: South England Supra-regional SOP on the Acute Management of Aortic Dissections (1 March 2024) — https://www.england.nhs.uk/south/wp-content/uploads/sites/6/2024/02/South-England-Supra-regional-SOP-on-the-Acute-Management-of-Aortic-Dissections-v1.0-FINAL-1.pdf NHS Retrieve: Aortic Dissection, version 1.3 (2025) — https://retrieve.nhs.uk/wp-content/uploads/2025/05/aortic-dissection-v1.3-160425.docx.pdf