Management of a Spontaneous Supra-aortic Arterial Dissection

A Case Report

Omar M. Sharaf; Tomas D. Martin; Eric I. Jeng

Disclosures

J Med Case Reports. 2021;15(283) 

In This Article

Discussion and Conclusions

Surgical treatment is the standard of care for arterial dissection involving the ascending aorta[4] to protect against proximal ascending aorta sequelae, including acute aortic insufficiency, coronary malperfusion, rupture, and tamponade. Reported cases of supra-aortic dissection varied in presentation and thus management. In one of the largest series reported of 27 patients over three decades, Kieffer et al.[5] found excellent results with surgical management. While some reported their surgical interventions when there was concern for rupture,[6] others argue for early surgical intervention in this entity.[7] Some groups recommend medical management when vessel diameter is less than 3 cm and there is no evidence of distal emboli or malperfusion.[8,9] Unless there is evidence of persistent growth, rupture, and/or neurologic deficit related to dissection flaps, we treat acute presentations of supra-aortic dissections non-operatively. Our current outpatient management algorithm for patients with supra-aortic dissection without evidence of rupture or end-organ malperfusion includes anti-impulse beta-blocker and calcium channel blocker therapy with target systolic pressure of less than 120 mmHg and heart rate of less than 80 beats per minute, an antiplatelet regimen with aspirin, and close follow-up with CTA imaging to monitor aneurysmal growth. The long-term management of this patient will likely include an aortic debranching with individual bypasses to the right carotid and axillary arteries once aneurysmal degeneration worsens. We believe that initial non-operative management of uncomplicated supra-aortic dissections enables surgeons to transition intervention from urgent/emergent status to a purely elective operation, potentially also improving the surgical outcomes for this rare presentation.

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