A 72-year-old man with hypertension and a 50 pack-year smoking history presents to the emergency department with sudden-onset severe tearing chest pain radiating to the interscapular region. His BP is 185/100 mmHg in the right arm and 140/80 mmHg in the left arm. ECG shows no ST changes. CXR reveals a widened mediastinum. CT aortogram confirms a Type A aortic dissection involving the ascending aorta. What is the definitive management?

• A Thoracic endovascular aortic repair (TEVAR)
• B IV labetalol infusion to reduce BP and heart rate, followed by re-imaging
• C Emergency surgical repair of the ascending aorta under cardiopulmonary bypass ✓
• D Thrombolysis with alteplase for suspected coronary dissection

Explanation

Stanford Type A aortic dissection (involving the ascending aorta) carries an untreated mortality of approximately 1–2% per hour in the first 48 hours. It is a surgical emergency requiring immediate open repair under cardiopulmonary bypass to prevent rupture, cardiac tamponade, coronary ostial occlusion, or stroke. Medical management (IV beta-blockade) is the treatment for Type B dissection (not involving the ascending aorta) and as temporising bridging for Type A only. TEVAR is used for Type B dissections with complications. Thrombolysis is absolutely contraindicated as it would cause fatal haemorrhage into the aortic wall.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

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Written and medically reviewed by the StethoPrep medical team.