Management and outcomes of thoracic dissection in older adults

Aortic dissection carries significant morbidity and mortality, particularly with involvement of the ascending aorta. The estimated prevalence of aortic dissection in the general population is between 2.0 and 3.5 per 100,000 people; the risk of which increases with age and underlying risk factors, such as hypertension, long-term tobacco use, and genetic aortopathy. The older adult population continues to increase exponentially, with people older than 65 years accounting for nearly 20% of the total population. The unique challenges associated with treating older patients include consideration of reduced physiologic reserve, increased comorbidity profiles, and clinical frailty. Although surgical repair and endovascular repair have notable survival benefits in the setting of acute aortic dissection, older patients are more frequently offered medical management alone. More recently, the proliferation and evolution of endovascular therapies has offered novel and minimally invasive treatment options for older patients with acute and chronic post-dissection thoracoabdominal aortic aneurysms. In this article, the underlying risk factors, pathophysiology, and clinical decision making for patients with acute dissection are described. In addition, the considerations for treatment of both acute and chronic aortic dissection in this unique patient population are outlined.