Acute Aortic Disease.. - Index of

Classification of Aortic Dissection 17
Figure 9 Imminent malperfusion syndrome in an initially stable patient emerging as
complicated type B dissection with invagination of the dissecting lamella into celiac trunk
(left) and true lumen collapse from systemic pressure in the false lumen (right).
(“the deadly triad”) should be taken into consideration for risk assessment and
decision-making (40,41,74).
Complicated vs. Noncomplicated Dissection
Another clinically useful way to stratify is to differentiate between complicated
and uncomplicated dissection, regardless of both the time elapsed since onset of
dissection and proximity of the dissected segments of the aorta. Any proximal
aortic dissection deserves an ultimate effort to save the life of the patient.
An assessment of impending risk regardless of swift surgery is possible by use of
the IRAD risk prediction model as illustrated in Figure 8. The clinical features
listed in Figure 8 are associated with scoring points and add up to a risk prediction
score that allows a realistic assessment of individual prognosis in proximal dissection
(75). The modelled probability of death is closely reflected in the observed
in-hospital mortality of proximal dissection cases.
Even more clinically applicable is the distinction between complicated and
uncomplicated type B dissections. A recent analysis from the IRAD group identified
variables in type B dissection associated with increased risk of in-hospital
mortality that may help clinicians in risk stratification and decision-making
(Table 5). Type B dissection is generally associated with a more favourable
outcome (short- and mid-term) than type A lesions, but decision-making may be
more complex due to an emerging variety of treatment options. In contrast to
type A dissection, which requires surgical attention even in uncomplicated cases,
medical management with antihypertensive and cardiac output suppressing
drugs is currently the preferred strategy in uncomplicated type B dissection.
Complicated type B lesions (contained rupture, malperfusion from compromised
side branches, rapid enlargement) have traditionally required open surgical repair,