combined vasodilator and negative inotropic effects. if the individual has refractory hypertension (persistent hypertension on the maximum doses of three different classes of antihypertensive agents), involvement of the renal arteries in the aortic dissection plane should be considered. surgical indications for the surgical treatment of aortic dissection include an acute proximal aortic dissection and an acute distal aortic dissection with one or more complications. complications include compromise of a vital organ, rupture or impending rupture of the aorta, retrograde dissection into the ascending aorta. these are more common with a history of marfan syndrome or ehlers-danlos syndrome. the objective in the surgical management of aortic dissection is to resect (remove) the most severely damaged segments of the aorta and to obliterate the entry of blood into the false lumen (both at the initial intimal tear and any secondary tears along the vessel). while excision of the intimal tear may be performed, it does not significantly change mortality. the particular treatment used depends on the segment or segments of the aorta involved. some treatments are: open aortic surgery with replacement of the damaged section of the aorta with a tube graft (often made of dacron) when no damage to the aortic valve is seen bentall procedure – replacement of the damaged section of the aorta and replacement of the aortic valve david procedure – replacement of the damaged section of the aorta and reimplantation of the aortic valve thoracic endovascular aortic repair, a minimally invasive surgical procedure usually combined with ongoing medical management replacement of the damaged section of the aorta with a sutureless vascular ring connector-reinforced dacron graft: the vascular ring connector is a titanic ring used as a stent in the vascular graft to achieve a quick, blood-sealed, and sutureless anastomosis. two furrows on the surface of the ring are for fixation of the vascular graft and the aorta. the tapes used to tie against the ring provide a larger contact surface area than the traditional stitches, thus it provides stronger anastomosis and better surgical results. a number of comorbid conditions increase the surgical risk of repair of an aortic dissection. these conditions include the following: prolonged preoperative evaluation (increased length of time prior to surgery) advanced age comorbid disease states (e.g.: coronary artery disease) aneurysm leakage cardiac tamponade shock - obstructive shock past history of myocardial infarction history of kidney failure (either acute or chronic kidney failure) follow-up closure of the lumen of a type b aortic dissection following medical management the long-term follow-up in individuals who survive aortic dissection involves strict blood pressure control. the relative risk of late rupture of an aortic aneurysm is 10 times higher in individuals who have uncontrolled hypertension, compared to individuals with a systolic pressure below 130 mmhg. the risk of death is highest in the first two years after the acute event, and individuals should be followed closely during this time period. about 29% of late deaths following surgery are due to rupture of either a dissecting aneurysm or another aneurysm. in addition, a 17% to 25% incidence exists of new aneurysm formation, typically due to dilatation of the residual false lumen. these new aneurysms are more likely to rupture, due to their thinner walls. serial imaging of the aorta is suggested, with mri being the preferred imaging technique. prognosis risk of death in untreated type a aortic dissection risktimespan 25%in first 24 hours 50%in first 72 hours 80%in two weeks 90%in first month of all people with aortic dissection, 40% die immediately and do not reach a hospital in time. of the remainder, 1% die every hour, making prompt diagnosis and treatment a priority. even after diagnosis, 5–20% die during surgery or in the immediate postoperative period. in ascending aortic dissection, if surgery is decided to be not appropriate, 75% die within 2 weeks. with aggressive treatment, 30-day survival for thoracic dissections may be as high as 90%. epidemiology establishing the incidence of aortic dissection has been difficult because many cases are only diagnosed after death (which may have been attributed to another cause), and is often initially misdiagnosed. aortic dissection affects an estimated 2.0–3.5 people per every 100,000 every year. studies from sweden suggest that the incidence of aortic dissection may be rising. men are more commonly affected than women: 65% of all people with aortic dissection are male. the mean age at diagnosis is 63 years. in females before the age of 40, half of all aortic dissections occur during pregnancy (typically in the third trimester or early postpartum period). dissection occurs in about 0.6% of pregnancies. history the earliest fully documented case of aortic dissection is attributed to frank nicholls in his autopsy report of king george ii of great britain, who had been found dead on 25 october 1760; the report describes a dissection of the aortic arch and into the pericardium. the term "aortic dissection" was introduced by the french physician j. p. maunoir in 1802, and rené laennec labeled the condition "dissecting aneurysm". london cardiologist thomas bevill peacock contributed to the understanding of the condition by publishing two series of the cases described in the literature so far: 19 cases in an 1843 review, and 80 in 1863. the characteristic symptom of tearing pain in the chest was recognized in 1855 when a case was diagnosed in life. surgery for aortic dissection was first introduced and developed by michael e. debakey, denton cooley, and oscar creech, cardiac surgeons associated with the baylor college of medicine, houston, texas, in 1954. debakey developed aortic dissection himself at age 97 in 2005, and underwent surgery in 2006. endovascular treatment of aortic dissection was developed in the 1990s. society and culture ritter rules are a compilation of reminders, symptoms, and risk factors designed to prevent the misdiagnosis of thoracic aortic dissection. the rules were named after three's company star john ritter, who died from a thoracic aortic dissection in 2003 after he was misdiagnosed and accidentally treated for a heart attack by his two doctors. the rules were developed by dianna milewicz of the university of texas health science center at houston seven years after ritter's premature death, and were jointly published by the non-profit organization in ritter's honor and the thoracic aortic disease coalition. lucille ball was diagnosed with dissecting aortic aneurysm and underwent surgery to repair her aorta and a successful seven-hour aortic valve replacement, but died days later. a greater incidence of aortic aneurysm is seen in cigarette smokers; ball had been a heavy smoker most of her life. playwright jonathan larson, best known for the musical rent, died in 1996 of an aortic dissection believed to be due to undiagnosed marfan syndrome. days of our lives and babylon 5 actor richard biggs died on may 22, 2004 at the age of 44 due to complications from aortic dissection. lux interior of the cramps died at the glendale memorial hospital on february 4, 2009, at the age of 62, following an aortic dissection which, contrary to initial reports about a pre-existing condition, was "sudden, shocking and unexpected". alan thicke died in 2016 of type-a aortic dissection at the providence saint joseph medical center in burbank, at the age of 69. japanese actress hiromi tsuru died in her car from aortic dissection in 2017 at the age of 57. taiwanese entertainer alien huang died in 2020 at the age of 36. kentaro miura, writer and artist of the manga berserk, died from aortic dissection in 2021 at the age of 54. in august 2021, new zealand cricketer chris cairns was put on full life support following an aortic dissection in his home in canberra, australia. he was transferred to sydney, and became paralysed from the waist down due to sustaining a stroke during surgery. 41-year-old guitarist richie faulkner of the heavy metal band judas priest had an aortic aneurysm on september 27, 2021, in the middle of the final song of their 50-minute set at a music festival. he underwent 10+1⁄2 hours of open heart surgery to repair the aortic dissection. in may 2022, keyboardist andy fletcher, a founding member of the uk band depeche mode, died unexpectedly at home from an aortic dissection, at the age of 60.