ETD

• acute aortic syndrome

Background m- Acute aortic syndromes (AAS), including type B aortic dissection (TBAD), penetrating aortic ulcer (PAU), and intramural hematoma (IMH), represent a spectrum of potentially life-threatening conditions. While endovascular repair is clearly indicated in complicated presentations, optimal management of uncomplicated AAS remains controversial. Current international guidelines recommend best medical therapy (BMT) with close surveillance as first-line treatment in uncomplicated cases; however, long-term outcome data beyond mid-term follow-up are scarce.
Objectives - This study aimed to evaluate long-term clinical and aortic outcomes of patients with uncomplicated TBAD, PAU, and IMH managed with BMT, focusing on survival, disease progression, and the need for delayed aortic intervention over extended follow-up.
Methods - We performed a retrospective observational analysis of 100 consecutive patients admitted with a diagnosis of acute aortic syndrome over a 10-year period at a tertiary referral center. Fifty patients presented with uncomplicated TBAD, PAU, or IMH and were treated conservatively with BMT. Uncomplicated status was defined by the absence of aortic rupture, malperfusion syndromes, refractory pain, uncontrolled hypertension, or rapid aortic expansion at presentation. Best medical therapy consisted of strict blood pressure and heart rate control, combined with scheduled clinical and radiological follow-up using serial cross-sectional imaging. Primary endpoints were aortic-related mortality and overall survival. Secondary endpoints included freedom from aortic intervention and progression of aortic disease. Mean follow-up exceeded 5 years.
Results - Among the 50 patients treated conservatively, long-term outcomes were favorable. During follow-up, 45 patients (90%) remained free from aortic intervention. Five patients (10%) required delayed aortic repair due to documented disease progression, including aortic enlargement or evolution to a complicated course. Aortic-related mortality was low: only one patient (2%) died due to progression of aortic disease without undergoing intervention. No early aortic ruptures were observed in the medically managed cohort. The remaining patients demonstrated stable clinical conditions and acceptable aortic stability on imaging surveillance throughout long-term follow-up. Overall survival was high, and most adverse events occurred late and were preceded by radiological signs of disease progression.
Conclusions - In this single-center experience with a mean follow-up exceeding five years, best medical therapy for uncomplicated TBAD, PAU, and IMH was associated with excellent long-term outcomes. The majority of patients remained free from aortic-related death and delayed intervention, with a very low rate of fatal disease progression. These findings support BMT as a durable and safe first-line strategy in carefully selected patients with uncomplicated acute aortic syndromes, provided that strict clinical and imaging surveillance is maintained. Long-term follow-up is essential to identify late disease progression and optimize timing of intervention when required.