1. TBAD presents with sudden, severe, tearing chest or back pain. Look for significant hypertension, pulse deficits, or signs of malperfusion (e.g., limb ischemia, abdominal pain). 20% of patients may be asymptomatic. The chronicity of the dissection should be assessed as it impacts the risk of mortality and efficacy of intervention. This ranges from Hyper acute (<24 hours), acute (1-14 days), subacute to chronic (15 to >90 days)

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2. CT angiography is the gold standard for diagnosing Type B dissection. TBAD involves the descending aorta, distal to the left subclavian artery. If CT is contraindicated, TEE or MRI can be used. POCUS may identify an intimal flap or an aneurysm.

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3. Aggressive BP management: Start IV beta-blockers (e.g., labetalol) to reduce heart rate (target <60 bpm) and SBP (target <120 mmHg). Add on Calcium channel blockers, ace inhibitors and nitrates. Pain control with opioids reduces sympathetic drive.

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4. Identify complicated cases: Complicated TBAD involve features of rupture/impending rupture and malperfusion. Malperfusion may be due to static or dynamic branch vessel obstruction. Look for refractory pain, rapid aortic expansion, uncontrollable hypertension, or compromise of the renal, mesenteric, spinal, or lower extremity vasculature.

 

5. Complicated dissection patients benefit from early TEVAR. Open surgery can be considered in complicated TBAD who have unsuitable anatomy for TEVAR. Very early TEVAR (<24 hours) may increase the risk of periprocedural complications, particularly type A dissection. The surgical goals are to reduce the risk of rupture, restore organ perfusion, reduce false lumen flow and prevent aneurysm formation.