ICU · Cardiovascular

Acute aortic dissection: type A vs type B, malperfusion, and endovascular management

Also known as Aortic dissection · Type A dissection · Type B dissection · Stanford classification · TEVAR · Malperfusion syndrome

Acute aortic dissection = tear in aortic intima - blood enters media - false lumen - propagation. CLASSIFICATION (Stanford): TYPE A (ascending aorta — 65%) — SURGICAL EMERGENCY (mortality 1-2%/h untreated, 50% in 48h). TYPE B (descending aorta — distal to left subclavian — 35%) — MEDICAL management (beta-blockers, BP control); surgery/endovascular if COMPLICATED (rupture, malperfusion, refractory pain/HTN, rapid expansion). PRESENTATION: sudden TEARING chest/back pain (migrating — tracks dissection propagation), pulse deficits (asymmetric — vessel occlusion), blood pressure differential (20 mmHg between arms), new aortic regurgitation murmur, neurological deficit (stroke, paraplegia — spinal/visceral ischaemia), syncope. RISK FACTORS: hypertension (most important), connective tissue disease (Marfan, Ehlers-Danlos, Loeys-Dietz), bicuspid aortic valve, pregnancy, cocaine, trauma. DIAGNOSIS: CT aortogram (gold standard — intimal flap, true/false lumen, extent, malperfusion). MANAGEMENT: TYPE A — emergency SURGICAL repair (ascending aorta replacement ± AVR ± arch). TYPE B (uncomplicated) — medical (beta-blocker + BP control). TYPE B (complicated) — THORACIC ENDOVASCULAR AORTIC REPAIR (TEVAR) preferred over open surgery. MORTALITY: type A (untreated) 50% in 48h; type B (uncomplicated) 10% in 30 days.