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(Class I) (Class IIa) (Class IIa) (Class I) Acute type A aortic dissection Acute type B aortic dissection Check for presence of acute type A aortic dissection complications Aortic rupture or CPR Tamponade Consider pericardial drainage Cerebral malperfusion or stroke Mesenteric malperfusion Lower extremity malperfusion Invasive diagnostics and/or percutaneous malperfusion repair or TEVAR/EVAR If not performed before aortic surgery and malperfusion persists, optional angiographic control and/or percutaneous malperfusion repair/TEVAR/EVAR Direct admission to hybrid-OR with onsite aortic team Anaesthesiological monitoring and intraoperative TOE (if feasible) and preparation for surgery Immediate aortic surgery (ascending and consider aortic arch or FET based on extension) Angiographic control and/or percutaneous malperfusion repair or TEVAR or EVAR Check for presence of acute type B aortic dissection complications If malperfusion persists Aortic rupture/ tamponadea Cerebral malperfusion/strokea Mesenteric malperfusion Lower extremity malperfusion TEVAR or EVAR and/or percutaneous malperfusion repair Static thrombus thrombus Dynamic Static + dynamic F T thrombus Consider pericardial drainage In case of retrograde aortic dissection, immediate aortic surgery (ascending aorta, aortic arch or FET, based on extension) Consider extra-anatomic bypass if lower extremity malperfusion persists Figure 34 Mechanisms and clinical management of aortic branch obstruction in acute aortic dissection. CPR, cardiopulmonary resuscitation; F, false lumen; FET, frozen elephant trunk; OR, operating room; T, true lumen; TOE, transoesophageal echocardiography; TEVAR/EVAR, thoracic endovascular aortic aneurysm repair. aDevelops only in retrograde type A dissection. ESC Guidelines 3627 Downloaded from academic.oup.com/eurheartj/article/45/36/3538/7738955 by guest on 07 October 2026