Question 13

a)    Explain the medical management of a patient with confirmed Type B aortic dissection.
(60% marks).

b)    List the indications for consideration of non-medical management of this condition.
(40% marks)

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College answer

Not available.


The question asked "explain", not "list", which means a bit of discourse is called for:

Medical management:

  • Overall management goals:
    • Decrease aortic wall stress 
    • Thus, reduce the risk of rupture
    • Decrease the risk of propagation of the dissection flap
    • Maintain the perfusion of compromised organs
  • Haemodynamic objectives which serve these goals: 
    • Decrease cardiac contractility (dP/dT)
    • Decrease blood pressure
    • Decrease heart rate
  • Options to achieve these goals:
    • Labetalol infusion (15mg bolus, then 5mg/hr)
    • Alternatively, esmolol, verapamil, diltiazem
    • Once contractility and rate control is achieved,
      vasodilators can also be used (nitroprusside, clevidipine, etc)
    • Analgesia +/- sedation to decrease sympathetic output
  • Endpoints of therapy:
    • Systolic blood pressure 100-120 mmHg
    • HR < 70
    • Improved surrogate measures of organ perfusion

Indications for surgical management:

  • Complicated Type B dissection:
    • Features suggesting instability:
      • Aortic rupture
      • Refractory hypertension
      • Aortic total diameter of > 4.5 cm
      • Extension of dissection on repeat imaging
    • Ischaemia:
      • Visceral and renal ischaemia
      • Lower extremities ischaemia
      • Spinal cord ischaemia
    • Malperfusion:
      • Paraparesis or paraplegia
      • Abdominal pain, nausea, or diarrhea
      • Renal failure or LFT derangement
  • Uncomplicated Type B dissection
    • Can usually be managed conservatively
    • If the aorta is dilated (>4cm) or the false lumen is large (>22mm), surgical management may still be preferred to prevent long-derm aneurysmal degeneration


Aggarwal, Bhuvnesh, and Chad E. Raymond. "Therapeutic goals in patients with acute aortic dissection: management before surgery." Journal of the American College of Cardiology 65.15 (2015): 1599-1600.

Hiratzka, Loren F., et al. "2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease." Journal of the American College of Cardiology 55.14 (2010): e27-e129.

Goldfinger, Judith Z., et al. "Thoracic aortic aneurysm and dissection." Journal of the American College of Cardiology 64.16 (2014): 1725-1739.

Evangelista, Arturo, et al. "Insights from the international registry of acute aortic dissection: a 20-year experience of collaborative clinical research." Circulation 137.17 (2018): 1846-1860.

Tran, T. Paul, and Ali Khoynezhad. "Current management of type B aortic dissection." Vascular health and risk management 5 (2009): 53.

Harky, Amer, et al. "Systematic review and meta-analysis of acute type B thoracic aortic dissection, open, or endovascular repair." Journal of vascular surgery 69.5 (2019): 1599-1609.