[CK] Aortic dissection

LONG-TERM MANAGEMENTThere are three main management issues in patients who have survived the initial dissection: ongoing anti-impulse therapy, in the form of blood pressure lowering, to minimize aortic wall shear stress; evaluation for high-risk clinical conditions; serial imaging to detect signs of dissection progression, re-dissection, or aneurysm formation; and reoperation when indicated.

Anti-impulse therapy — Once heart rate control has been achieved and the patient is tolerating an oral diet, intravenous beta blocker (or other antihypertensive) therapy can be switched to an oral route. All patients should be maintained on lifelong therapy to reduce systemic blood pressure and the rate of rise in systolic pressure, both of which will minimize aortic wall stress [6]. Although not evaluated in controlled trials, we suggest a target blood pressure of less than 120/80 mmHg [6]. Combination antihypertensive drug therapy is usually required. => 120/80 and < 70(HR) 

Though unproven, avoidance of strenuous physical activity that would lead to a spike in blood pressure is also recommended as another method to minimize aortic shear stress. (See "Management of Marfan syndrome and related disorders", section on 'Restriction of strenuous activity'.)

Identifying associated genetic conditions — Similarly to thoracic aortic aneurysm, patients with thoracic aortic dissection should be evaluated for possible underlying genetic or familial disorders known to be related, which may increase their individual risk of progression or complications. Screening (transthoracic echocardiography) first-degree family members for aortic aneurysm (or bicuspid valve) should be considered. (See "Clinical features and diagnosis of acute aortic dissection", section on 'Incidence and associated conditions' and "Management of thoracic aortic aneurysm in adults", section on 'Identifying associated genetic conditions'.)

Serial imaging — We generally perform a baseline thoracic magnetic resonance (MR) or computed tomographic (CT) angiography prior to discharge, with follow-up examinations at 3, 6, and 12 months, and annually thereafter, even if the patient remains asymptomatic (and presuming the patient is a candidate for an intervention) [6,36]. (See 'Reintervention for endograft complications' below and 'Reoperation' below.)

The following abnormalities can be detected on serial imaging:

●Extension or recurrence of the dissection

●Aneurysm formation

●Leakage at surgical anastomotic or stent-graft component overlap sites

MR angiography is as accurate as transesophageal echocardiography (TEE), and because it is noninvasive, it is more acceptable for serial studies. MR angiography does not expose patients to iodinated contrast and ionizing radiation, which are important factors for younger patients who will likely have many years of serial monitoring, though due to concerns about long-term retained gadolinium, noncontrast MR angiography is an option that should be considered. CT angiography is an alternative, but it exposes the patient to considerable ionizing radiation and requires iodinated contrast, which may cause nephrotoxicity.

Alternating CT and MR angiography is a reasonable option for patients with good renal function. Noncontrast MR is an alternative for patients with impaired renal function. Transthoracic echocardiography is not considered a monitoring alternative, but it may be necessary to monitor ongoing valvular dysfunction.