Perioperative consideration of an asymptomatic aortic dissection

The vast majority of aortic dissections present with symptoms; completely asymptomatic cases are rare exceptions. Even without symptoms, aortic dissection carries a risk of life-threatening complications, such as rupture or end-organ malperfusion. In this report we describe a 59-year-old woman in whom a Stanford Type B aortic dissection was incidentally detected following transthoracic echocardiography, and confirmed using computed tomography aortogram. The dissection extended from just distal to the left subclavian artery to the bilateral common iliac arteries. Radiological features included a patent false lumen that was larger than the true lumen, conferring a high risk to the patient, although the entry tear measured only 0.7 cm. Clinically, she was younger than 60 years, but had a persistent heart rate >60 beats/minute, further increasing the risk of progression. Guidelines recommend optimal medical therapy for uncomplicated Type B dissections, focusing on blood pressure and heart rate control. In patients with high-risk features, trials such as ADSORB and INSTEAD-XL have suggested that prophylactic thoracic endovascular aortic repair may delay disease progression. However, our patient had significant frailty (Clinical Frailty Score 5) and multiple comorbidities, including poorly controlled asthma, obstructive sleep apnoea and heart failure. She was assessed to be at high risk of perioperative complications, adverse outcome or early postoperative mortality. In this context, the potential harms of prophylactic thoracic endovascular aortic repair outweighed the benefits. Through shared decision-making with the patient and her family, surveillance with optimal medical therapy was chosen, reserving the intervention for radiological or clinical progression. This case highlights the importance of risk stratification, frailty assessment and patient-centred decision-making in the management of asymptomatic Type B aortic dissection.