Longterm Followup And Treatment

The long-term approach to patients with successful initial treatment of acute aortic dissection or aneurysm begins with an appreciation that such patients have a systemic illness that variably predisposes their entire aorta and potentially its larger branches to dissection, aneurysm, and rupture. Systemic hypertension, advanced age, aortic size, and presence of a patent false lumen are all factors that identify higher risk, as does the entire spectrum of the Marfan's syndrome. However, all patients merit extremely aggressive medical therapy, follow-up visits, and serial imaging. It has been estimated that nearly a third of patients surviving initial treatment for acute dissection will experience dissection extension, aortic rupture, or require surgery for aortic aneurysm formation within 5 years of presentation. Furthermore, this risk is substantial in the first few months after initial therapy.

Treatment with effective beta blockade is the cornerstone of medical therapy. By lowering both blood pressure and contractility, beta blockers have been shown to retard aortic expansion in Marfan's syndrome30 and that associated with chronic abdominal aortic aneurysms31. Observational studies suggest similar unique benefits in aortic dissection when compared to other antihypertensive agents; guidelines recommend progressive uptitration of dosage to achieve a blood pressure <135/80 in usual patients and <130/80 in those with Marfan's syndrome31-33.

Serial imaging of the aorta is an essential component of long-term treatment and follow-up of patients with aortic aneurysm (before and after surgery or stent-graft placement) in Marfan's disease and in all cases of chronic dissection. Choice of imaging modality is dependent on institutional availability and expertise, extent of aortic involvement, and age of the patient. Previous recommendations suggest follow-up imaging and examination at 1, 3, 6, 9, and 12 months following discharge and annually thereafter34,35. This aggressive strategy underlines the observation that both hypertension and aortic expansion/dissection are common and not easily predicted in the first months following hospital discharge. Further, imaging is not confined simply to the region of initial involvement since both dissection and aneurysm formation may occur any where along the entire length of the aorta.

Development of an ascending aortic diameter of 4.5-5.0 cm is an indication for surgical repair in patients with Marfan's syndrome. For others, aorta's exceeding 5.5-6 cm warrant repair, as does distal aortic expansion to >6.0 cm in all types of patients. As with nondissecting aneurysms, rate of growth and size of the aorta are both important factors to consider when it comes to prophylactic vascular surgery. An ascending aortic aneurysm of 5.0 cm may merit urgent repair in a young patient with Marfan's syndrome36. Conversely, an aneurysm of 5.0 cm for 3 years an elderly person with well controlled blood pressure is unlikely to rupture.

Patients who have been treated with surgery and/or endovascular stent grafting warrant follow-up similar to those whose initial treatment was limited to medical treatment. Aortic expansion, dissection, and rupture both at the surgical suture site and at a distance are common in survivors of type A dissection. Meticulous attention to blood pressure control and serial imaging are just as relevant to operative survivors as for patients in early stages of aortic pathology.

Blood Pressure Health

Blood Pressure Health

Your heart pumps blood throughout your body using a network of tubing called arteries and capillaries which return the blood back to your heart via your veins. Blood pressure is the force of the blood pushing against the walls of your arteries as your heart beats.Learn more...

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