Answer
The definitive treatment for type B dissections is less clear. Uncomplicated distal dissections may be treated medically to control blood pressure. Distal dissections treated medically have a mortality rate that is the same as or lower than the mortality rate in patients who are treated surgically.
Surgery is reserved for distal dissections that are leaking, ruptured, or compromising blood flow to a vital organ.
Acute distal dissections in patients with Marfan syndrome usually are treated surgically.
Inability to control hypertension with medication is also an indication for surgery in patients with a distal thoracic aortic dissection.
Patients with a distal dissection are usually hypertensive, emphysematous, or older.
Long-term medical therapy involves a beta-adrenergic blocker combined with other antihypertensive medications. Avoid antihypertensives (eg, hydralazine, minoxidil) as these drugs would increase dP/dt (ie, rate of aortic pressure rise).
Survivors of surgical therapy also should receive beta-adrenergic blockers.
A series of patients with type B dissections demonstrated that aggressive use of distal perfusion, CSF drainage, and hypothermia with circulatory arrest improves early mortality and long-term survival rates.
Endovascular stenting remains an option for treatment of some type B dissections. Some studies recommend that patients with complicated acute type B dissections undergo endovascular stenting with the goal of covering the primary intimal tear. [6] More recent studies suggest that a combination medical therapy with endovascular aortic repair may inprove outcomes in acute and chronic uncomplicated type B dissections. [7]
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Aortic dissection
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Chest radiograph of a patient with aortic dissection. Image courtesy of Dr. K. London, University of California at Davis Medical Center.
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Chest radiograph of a patient with aortic dissection presenting with hemothorax.
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Chest radiograph demonstrating widened mediastinum in a patient with aortic dissection.
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Angiogram demonstrating dissection of the aorta in a patient with aortic dissection presenting with hemothorax.
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Electrocardiogram of a patient presenting to the ED with chest pain; this patient was diagnosed with aortic dissection.
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Patient with an ascending type A aortic dissection showing the intimal flap. Image courtesy of Kaiser-Permanente.
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Patient with an ascending type A aortic dissection showing the intimal flap. Image courtesy of Kaiser-Permanente.
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Patient with an ascending type A aortic dissection showing the intimal flap. Image courtesy of Kaiser-Permanente.
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Patient with an ascending type A aortic dissection showing the intimal flap. Image courtesy of Kaiser-Permanente.
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Patient with a type A aortic dissection involving the ascending and descending aorta. Image courtesy of Kaiser-Permanente.
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Patient with a type A aortic dissection involving the ascending and descending aorta. Image courtesy of Kaiser-Permanente.
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Patient with a type A aortic dissection involving the ascending and descending aorta. Image courtesy of Kaiser-Permanente.
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Patient with a type A aortic dissection involving the ascending and descending aorta. Image courtesy of Kaiser-Permanente.
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Patient showing a type B aortic dissection with extravasation of blood into the pleural cavity. Image courtesy of Kaiser-Permanente.
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Patient showing a type B aortic dissection with extravasation of blood into the pleural cavity. Image courtesy of Kaiser-Permanente.
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Patient showing a type B aortic dissection with extravasation of blood into the pleural cavity. Image courtesy of Kaiser-Permanente.
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Patient showing a type B aortic dissection with extravasation of blood into the pleural cavity. Image courtesy of Kaiser-Permanente.
