Acute and long-term management of aortic dissection

Acute aortic dissection occurs suddenly, often with symptoms including severe pain in the chest, back, or abdomen, or signs and symptoms of heart failure. These events are life-threatening and life-altering. 

The Penn Aorta Center has a specialized program to help people with aortic dissection recover and thrive. Recently, the Penn Medicine Physician Interviews Podcast welcomed Melanie Freas, DNP, CRNP, clinical program manager of the Center for Bicuspid Aortic Valve Diseases, and Katelyn Rosemann, MSN, CRNP, a cardiac surgery nurse practitioner and clinical coordinator at the Penn Heart and Vascular Center, to discuss aortic dissection care.

Acute and chronic aortic dissection 

An aortic dissection is considered acute in the first two weeks after the event. In this phase, the aorta is fragile, and medical teams must act quickly to stabilize the patient, control blood pressure and decide whether surgery is necessary, Freas says. “During the acute phase, the mortality rate is very high, so timing is very important,” she adds. 

Treatment depends on the type of dissection. “Most patients presenting acutely with a type A dissection, or a tear in the aorta closest to the heart, will need emergency open-heart surgery to survive. On the other hand, most patients who present acutely with a type B dissection—a tear in the aorta further down—will be managed with medications first, though some patients require surgery,” Freas observes. 

After an acute aortic dissection, patients are admitted to the hospital for close monitoring with CT scans and for surgery when indicated.

About four to six weeks after the initial dissection, patients are considered to be in the chronic phase. At that point, the body has adapted to altered blood flow patterns, and the aorta has become more stable. “Many patients live with chronic dissections for years with careful monitoring,” Freas says, though many will need additional surgery in the years that follow.

Once the aorta stabilizes, patients are monitored with CT imaging at 1, 3, 6, and 12 months, and then yearly.

Long-term monitoring for aortic dissection 

Following any aortic dissection, long-term surveillance is essential to ensure that surgical repairs are healing well and that the rest of the aorta remains stable. “One of the biggest misconceptions we see is the idea that surgery cures the problem, when in reality a dissection is a lifelong diagnosis. Even after a successful repair, the rest of the aorta still needs careful monitoring,” Rosemann says. 

“About one in five patients will need another procedure within 10 years of their initial repair, which is why staying connected to a specialized clinic makes such a difference,” she adds. “Our dissection clinic keeps patients plugged in with their surgeon and care team.” 

At the Penn Aorta Center, the care team includes cardiac and vascular surgeons and specialized advanced practice providers (APPs) who play a central role in patients’ ongoing care. APPs like Rosemann coordinate and independently interpret regular imaging, serve as the first point of contact for new symptoms or concerns, educate patients about their disease and lifestyle changes, and help them understand their follow-up plans. 

“In many ways, we're the steady partner, guiding patients through lifelong surveillance and helping to ensure nothing is missed,” Rosemann says. “At the Penn Aorta Center, we build a tailored lifelong surveillance plan for every patient supported by a dedicated team of surgeons, APPs, cardiologists, and geneticists. It's proactive, highly coordinated, and grounded in the latest guidelines and emerging treatment options designed to keep patients safe for the long haul.” 

If surveillance shows that the aorta is beginning to enlarge, affect blood flow to organs, or cause symptoms, follow-up care is transitioned back to the surgeon for intervention. Similarly, when surveillance indicates that a patient’s blood pressure is running higher, patients are connected to their primary care doctor or cardiologist for more aggressive blood pressure management. “The goal is always to act quickly before a problem becomes dangerous,” Rosemann notes.

Living with aortic dissection

Aortic dissection is a frightening experience. One survey by the Cleveland Clinic found that 22 percent of patients who were treated for dissection had post-traumatic stress disorder years after the event. Thus, for APPs at Penn Medicine, the goal isn’t just to help patients survive a dissection, but to help them learn how to live with a dissection, Rosemann says.

“One of the benefits of being followed in a specialized clinic for patients with aortic dissection is that patients feel that they're not alone in their diagnosis,” she says. 

No two aortic dissections look alike, she notes, and each patient requires a personalized approach to long-term care. “Once we establish where they were, where they are, and where we want to be, then we talk about their goals. And we build a plan that's safe, realistic, and tailored specifically to their condition to help them get back to a meaningful life again,” Rosemann says.

Aortic dissection research and education at Penn Medicine

Researchers, including scientists at Penn Medicine, have also made strides in predicting who is at risk for aortic dissection. Penn Medicine currently offers genetic testing for patients with a history of dissection, especially those under age 60, those with a strong family history of aortic dissection or aneurysm, and patients considered at risk for syndromic diseases. “It helps us understand individual risks, and it helps protect their relatives and loved ones,” Freas says. 

However, she cautions, a negative genetic test does not mean that a person does not have a gene related to aortic disease—just that the test is negative for the known variants that have been identified. “In the last 10 years, we've come a long way with our genetic testing and our ability to identify certain variants. But we have a long way to go,” Freas explains. “We're learning more and more every year, but we're not quite at the point where we want to offer genetic testing to everyone.”

Referrals and consultations

Melanie Freas, DNP, CRNP, and Katelyn Rosemann, MSN, CRNP, see patients at multiple Penn Heart and Vascular Center locations in Radnor and Philadelphia, PA. To refer a patient or request a consultation, please call 877-937-7366, or visit the online referral page.