R E V I E W Current management of type B aortic dissection T Paul Tran1 Ali Khoynezhad2 1Department of Emergency Medicine; 2Section of Cardiothoracic Surgery, University of Nebraska Medical Center, Omaha, NE, USA Correspondence: Ali Khoynezhad Section of Cardiothoracic Surgery, University of Nebraska Medical Center, 982315 Nebraska Medical Center, Omaha, NE 68198-2315, USA Tel +1 402 559 4424 Fax +1 402 559 6913 Email akhoynezhad@umc.edu Abstract: Acute aortic dissection is a life-threatening condition associated with high morbidity and mortality. In this article, the authors review basic biology of the aorta and aortic dissection, epidemiology, clinical presentation, diagnostic approach, emergency stabilization measures, and the latest surgical approach for type B dissection. Keywords: acute aortic dissection, aorta, diagnosis, management, review The tragedies of life are largely arterial. –Sir William Osler1 Perspective Diseases of the aorta are among the most feared conditions encountered in the emergency department. The term ‘acute aortic syndrome’ refers to a group of catastrophic diseases that affect the aorta. These include aneurysmal aortic rupture, intramural aortic hematoma, penetrating atherosclerotic ulcer, traumatic aortic transection, and acute aortic dissection (AAD). Acute aortic dissection is not an infrequent clinical entity. With more than 20 cases per million per year, AAD is actually the most common catastrophe of the aorta. It is a time-sensitive and rapidly fatal disease: If left untreated, early mortality from type A AAD can be as high as 1% per hour, 50% at 72 hours, 75% at two weeks, and 90% at three months.2–5 While hourly mortality data for type B AAD are not available, the overall in-hospital mortality is reported to be 11%. For those patients in the highest risk group, type B mortality can be as high as 71%.6 The classic clinical presentation of type B AAD is that of a male patient in his 60–70’s with a history of hypertension, who presents to the emergency department (ED) with the complaint of abrupt onset of severe, sharp, ripping chest and/or back pain. Patient appears in distress with pain, sweating, and anxious as in shock. Blood pressure may be normal or elevated. Physical examination may reveal a pulse deﬁcit, diastolic murmur, or focal neurological ﬁndings. Deﬁnitive imaging methods usually include a computed tomography (CTA) angiography. Critically ill patients will need deﬁnitive airway support, ﬂuid resuscitation, blood pressure and heart rate control, and emergent open surgical or endovascular repair. While type A AAD usually requires emergency surgical intervention, the major- ity of type B AAD (282 out of 386 [73%] in a recent series by Suzuki) are managed medically.7 With advances in understanding of the pathogenesis and pathophysiology of AAD, improved and aggressive antiimpulsive management, and the improvements in surgical/endovascular techniques, mortality from AAD has improved signiﬁcantly. The aim of this manuscript is, ﬁrst, to give an overview of aortic dissection and second, to focus on the contemporary approach to the diagnosis and medical management of type B acute aortic dissection. Vascular Health and Risk Management 2009:5 53–63 © 2009 Tran and Khoynezhad, publisher and licensee Dove Medical Press Ltd.This is an Open Access article which permits unrestricted noncommercial use, provided the original work is properly cited. 53