The most appropriate management for this patient is emergency aortic repair. She has a complicated type B aortic dissection. Type A dissections or intramural hematomas involve the ascending aorta or aortic arch, whereas type B syndromes begin distal to the left subclavian artery. Complicated dissections include occlusion of a major aortic branch leading to end-organ ischemia, persistent severe hypertension or pain, propagation of the dissection (which may be manifested by persistent or recurrent pain), aneurysmal expansion, and rupture. This patient has new acute kidney failure because the dissection occludes the renal arteries. Emergency surgery is recommended for acute type A and complicated type B dissections; initial medical management is recommended for uncomplicated type B dissections. Because this patient has a complicated type B dissection, medical management alone would not be appropriate.

Because patients with aortic dissection have a significant prevalence of coronary artery disease, coronary angiography is sometimes performed prior to surgical intervention to allow for repair prior to or at the time of operation for treatment of the aortic dissection. However, the benefit of this approach has not been established, and the required contrast administration would be potentially harmful in this patient with acute kidney failure caused by her aortic dissection. It would therefore not be an appropriate next step in the treatment of this patient.

Although some variants of aortic dissection are associated with intramural thrombus, antithrombotic or thrombolytic therapy is contraindicated and may be potentially fatal in patients with aortic dissection. This highlights the need to exclude aortic dissection prior to initiating either therapy, which may be indicated in patients with evidence of cardiac ischemia.