A 58-year-old hypertensive man presents with sudden interscapular pain. CT angiography shows a dissection beginning just distal to the left subclavian artery origin and extending to the iliac bifurcation. He has no malperfusion and is normotensive. Initial management is:

• A Immediate surgical repair via left thoracotomy
• B Thrombolysis
• C Systemic heparinisation followed by endovascular stenting within 24 hours
• D Intravenous beta blockade to control heart rate and blood pressure ✓

Explanation

This is a Stanford type D dissection (distal to the left subclavian artery). Uncomplicated type D dissection is managed medically with aggressive rate and pressure control, typically intravenous beta blockers such as labetalol, because early intervention carries higher mortality than medical therapy. Thrombolysis is contraindicated, and surgery or TEVAR is reserved for complications such as rupture, malperfusion, refractory pain, or rapid expansion.

Reference: Schwartz's Principles of Surgery, 11th ed.

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Written and medically reviewed by the StethoPrep medical team.