Aortic emergencies

Acute aortic dissections account for the leading and most feared of aortic emergencies. Acute dissections are associated with a dreadful mortality rate; therefore, an accurate diagnosis and immediate treatment are mandatory. The key point of a lifesaving management strategy is the distinction between acute type A dissection, uncomplicated type B dissection, and complicated type B dissection, and those including contained ruptured aorta (severe pleural effusion) and/or malperfusion syndrome (by end-organ ischaemia: paraplegia, intestinal ischaemia, renal insufficiency, limb ischaemia). Type A generally requires urgent surgery; uncomplicated type B dissections are treated conservatively, while complicated type B dissections are currently managed by means of minimally invasive endovascular techniques, eventually associated with a tight surgical time (e.g. in the case of limb ischaemia). Surgical repair of type A dissection consists of the replacement of the ascending aorta. The repair is extended proximally towards the aortic root and valve, and distally towards the aortic arch, in function of the lesions found and the clinical presentation of the patient (haemodynamic status, age, comorbidities). The emergence of endovascular techniques and the contribution of thoracic endovascular aortic repair, with thoracic stent-grafts deployed from the proximal descending aorta to reopen the true lumen and to seal the entry tear in type B dissections, have revolutionized the surgical treatment algorithm in this pathology, and thus the patient’s immediate and medium-term survival. In the same group of acute aortic syndromes, traumatic aortic isthmic ruptures are also life-threatening conditions and account for one of the main causes of death at the time of traumatic accidents. As in the case of complicated type B dissections, the introduction of aortic stent-grafts has changed the outcome of these patients.