Aortic dissection: from aetiology to therapeutic management

Acute aortic dissection remains a challenging clinical emergency with a high mortality rate. The peak incidence of aortic dissection is in the sixth and seventh decade of life; men are affected twice as commonly as women. Two classification systems predominate, the DeBakey and the Stanford classification. In both systems, aortic dissections with and without ascending aortic involvement are distinguished for prognostic and therapeutic reasons. In general, surgery is indicated in dissections involving the ascending aorta, where as medical management or endovascular stent-graft implantation is reserved for dissections without ascending aortic involvement. Echocardiography, contrast-enhanced CT, MRI and aortography are currently used to confirm the diagnosis. Their diagnostic accuracies are similar, but they differ in the ability to detect complications associated with dissection. Initial therapeutic aims include elimination of pain and reduction of systolic blood pressure to 120 mm Hg or less by the use of ß-blockers and vasodilators. Long-term medical therapy to control hypertension is of greatest importance in all patients who have survived aortic dissection, to reduce late complications such as recurrent dissection, formation of an aneurysm or impending rupture of a dissecting aneurysm. The primary aim of long-term surveillance is early detection of unstable aortic lesions and requires subsequent surgical or interventional measures.