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• W3157470475 abstract "Central MessageFor acute TBAD with rupture and malperfusion, TEVAR is the first-line treatment. Increasing evidence shows that TEVAR is beneficial for patients with high-risk clinical or radiographic features.See Commentaries on pages 1066 and 1067. For acute TBAD with rupture and malperfusion, TEVAR is the first-line treatment. Increasing evidence shows that TEVAR is beneficial for patients with high-risk clinical or radiographic features. See Commentaries on pages 1066 and 1067. Feature Editor's Introduction—The approach to acute aortic syndromes is evolving rapidly as endovascular therapies are refined and hybrid approaches with open surgical techniques and combinations of endovascular therapy with optimal medical management are being investigated. This is changing the potential landscape of treatment of aortic dissection. The perioperative care of these patients is being transformed accordingly, and the concept of aortic centers is solidifying to better care for complex aortic disease. Of the different classifications of aortic dissection, the most widely used is the Stanford Classification, in which type A aortic dissection and type B aortic dissection (TABD) are defined based on the origin of the intimal tear proximal or distal to the left subclavian artery, respectively. Traditionally, this classification system has been successful due to the easy recognition and practical therapeutic approach. Where acute type A aortic dissection is typically a surgical emergency, the traditional management of TBAD is primarily medical management where pain control and blood pressure control with an emphasis on anti-impulse therapy are the cornerstones of treatment given the high morbidity and mortality associated with open surgery. Notwithstanding, in parallel to the growth of endovascular therapies, there has been increased study on the benefits of endovascular approaches to TBAD, increasing the options to manage this aortic syndrome. In this important Invited Expert Opinion article, Preventza and colleagues discuss the advances and controversies in the evolving approach to TBAD. The authors start by describing the deficiencies of the current classification system and the new classifications being developed to address them. As important as the anatomic classification is the crucial role of time and the authors describe the updated definitions regarding timing of aortic dissection from hyperacute (<24 hours) to chronic (>90 days) and how this facilitates decision making regarding use of endovascular techniques as the characteristics of the dissection flap change with time. An essential section on TBAD complications and high-risk features is included, and the authors also review the evidence on the endovascular approach to TBAD, including strategies and indications, timing, and different trials to date. They also cover intraoperative adjuncts, such as use of intravascular ultrasound and spinal fluid drainage. Finally, they describe their approach to TABD, including intraoperative and postoperative tips. This article is timely because it describes how TBAD is not just a medical emergency. Endovascular approaches could complement optimal medical therapy in addition to providing guidance on what constitutes a high-risk TBAD and what to consider when managing these patients at established aortic centers. Juan N. Pulido, MD The optimal management of acute type B aortic dissection (TBAD) remains to be determined. Traditionally, this clinical entity has been managed medically because of the high risk of morbidity and mortality that was associated with open surgery. Acute TBAD is a complex disease that can have a variety of presentations. Thus, the terms complicated and uncomplicated aortic dissection, which are often used in the literature, are misleading given the natural history, presentations, and complications of the disease. High-risk characteristics often preclude favorable outcomes when treatment consists solely of medical management. In recent years, new endovascular approaches have been developed to address TBAD. These new approaches supplement medical management and are essential to achieving successful outcomes for patients with complicated TBAD. In the Stanford classification, which is the most widely used system because of its simplicity, TBAD is defined by an intimal tear originating distal to the left subclavian artery.1Daily P.O. Trueblood H.W. Stinson E.B. Wuerflein R.D. Shumway N.E. Management of acute aortic dissections.Ann Thorac Surg. 1970; 10: 237-247Abstract Full Text PDF PubMed Scopus (869) Google Scholar According to the DeBakey classification,2Debakey M.E. Henly W.S. Cooley D.A. Morris Jr., G.C. Crawford E.S. Beall Jr., A.C. Surgical management of dissecting aneurysms of the aorta.J Thorac Cardiovasc Surg. 1965; 49: 130-149Abstract Full Text PDF PubMed Google Scholar distal dissections are characterized by the origin of the intimal tear and the extent of the dissection. The type III aortic dissection is divided into 2 subtypes: type IIIA (limited to the descending thoracic aorta) and type IIIB (extension below the diaphragm). Neither the Stanford and nor the DeBakey classification addresses dissections originating within the aortic arch (Figure 1). Consequently, 2 new classification systems have been developed to address dissections involving the aortic arch. The Society of Thoracic Surgery (STS) and Society of Vascular Surgery (SVS) classification system is based on aortic zones.3Lombardi J.V. Hughes G.C. Appoo J.J. Bavaria J.E. Beck A.W. Cambria R.P. et al.Society for Vascular Surgery (SVS) and Society of Thoracic Surgeons (STS) reporting standards for type B aortic dissections.Ann Thorac Surg. 2020; 109: 959-981Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar TBAD is defined by an entry tear originating distal to the innominate artery (in or distal to aortic zone 1). The proximal and distal extent of the dissection is described by its aortic zones. The STS/SVS classification system is intended to facilitate data collection for research, allowing a detailed, standardized description of aortic disease. Although invaluable for examining study populations, this classification system is challenging to translate into clinical treatment options; the cardiovascular surgery community needs a user-friendly way of doing so (Figure 2). The European Association for Cardio-Thoracic Surgery (EACTS) and European Society for Vascular Surgery system classify aortic dissection as type non-A–non-B when the aortic arch is affected. This class includes 2 different mechanisms of injury: an entry tear originating within the arch, and retrograde dissection.4Czerny M. Schmidli J. Adler S. van den Berg J.C. Bertoglio L. Carrel T. et al.Current options and recommendations for the treatment of thoracic aortic pathologies involving the aortic arch: an expert consensus document of the European Association for Cardio-Thoracic Surgery (EACTS) and the European Society for Vascular Surgery (ESVS).Eur J Cardiothorac Surg. 2019; 55: 133-162Crossref PubMed Scopus (236) Google Scholar A separate classification for aortic arch involvement was created to reflect a significantly worse prognosis in cases involving injury to the arch than in dissections originating distal to the left subclavian. The proposed EACTS/European Society for Vascular Surgery classification system is simpler than the STS/SVS system and may be more user friendly for practicing cardiovascular surgeons (Figure 3). Currently, neither of the 2 newer anatomic classification systems has been proven superior in aiding decision making regarding medical or endovascular intervention in acute cases. Therefore, further validation is needed from the cardiovascular community. The STS/SVS and EACTS/European Society of Cardiology reporting standards and recommendations have updated definitions regarding the timing of aortic dissection: hyperacute <24 hours, acute 1 to 14 days, subacute 15 to 90 days, and chronic >90 days.3Lombardi J.V. Hughes G.C. Appoo J.J. Bavaria J.E. Beck A.W. Cambria R.P. et al.Society for Vascular Surgery (SVS) and Society of Thoracic Surgeons (STS) reporting standards for type B aortic dissections.Ann Thorac Surg. 2020; 109: 959-981Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar,5Erbel R. Aboyans V. Boileau C. Bossone E. Bartolomeo R.D. Eggebrecht H. et al.2014 ESC guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC).Eur Heart J. 2014; 35: 2873-2926Crossref PubMed Scopus (2922) Google Scholar These proposed demarcations of chronicity reflect that mortality significantly decreases beyond 14 days. This change in classification is notable because it facilitates decision making regarding endovascular treatment given that the dissection flap is still compliant and amenable to thoracic endovascular aortic repair (TEVAR) within 90 days of the index event. In addition to the abovementioned classification systems, 2 more classifications have been previously proposed. In 2012, Augoustides and colleagues6Augoustides J.G. Szeto W.Y. Woo E.Y. Andritsos M. Fairman R.M. Bavaria J.E. The complications of uncomplicated acute type-B dissection: the introduction of the Penn classification.J Cardiothorac Vasc Anesth. 2012; 26: 1139-1144Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar proposed the Penn Classification system: 4 classes of clinical presentation based on the presence of branch-vessel malperfusion, circulatory compromise, or both. Dake and colleagues7Dake M.D. Thompson M. van Sambeek M. Vermassen F. Morales J.P. DISSECT: a new mnemonic-based approach to the categorization of aortic dissection.Eur J Vasc Endovasc Surg. 2013; 46: 175-190Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar in 2013 proposed the DISSECT classification system, which is based on 6 characteristics that could influence therapeutic options: duration of disease, intimal tear location, size of the dissected aorta, segmental extent of aortic involvement, clinical complications of the dissection, and thrombus within the aortic false lumen. Since their introduction (2012 and 2013), neither of these classification systems has been widely adopted. Two life-threatening complications that arise from acute TBAD are rupture and malperfusion.8Malaisrie S.C. Mehta C.K. Updates on indications for TEVAR in Type B aortic dissection.Innovations (Phila). 2020; 15: 495-501Crossref PubMed Scopus (8) Google Scholar Rupture with extravasation outside the adventitia of the aorta manifests as a hemothorax or a periaortic or mediastinal hematoma.3Lombardi J.V. Hughes G.C. Appoo J.J. Bavaria J.E. Beck A.W. Cambria R.P. et al.Society for Vascular Surgery (SVS) and Society of Thoracic Surgeons (STS) reporting standards for type B aortic dissections.Ann Thorac Surg. 2020; 109: 959-981Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar Malperfusion is the most common indication for emergency intervention and is the result of inadequate blood flow to a tissue bed (cerebral, renal, visceral, iliofemoral, or spinal cord).8Malaisrie S.C. Mehta C.K. Updates on indications for TEVAR in Type B aortic dissection.Innovations (Phila). 2020; 15: 495-501Crossref PubMed Scopus (8) Google Scholar It is further characterized by dynamic or static mechanisms. Dynamic malperfusion occurs when, during the cardiac cycle, changes in blood flow and pressure between the true and false lumens cause intermittent obstruction of a branch vessel by the mobile dissection flap of the vessel's orifice. Dynamic mechanisms cause 80% of all malperfusion syndromes.9Crawford T.C. Beaulieu R.J. Ehlert B.A. Ratchford E.V. Black III, J.H. Malperfusion syndromes in aortic dissections.Vasc Med. 2016; 21: 264-273Crossref PubMed Scopus (65) Google Scholar Static malperfusion occurs when there is a fixed obstruction of the true lumen due to intussusception of the intimal flap into the branch vessel, dissection extending into the branch vessel with narrowing or thrombosis, or continuous pressurization of the false lumen throughout the cardiac cycle. In many cases, both dynamic and static mechanisms are present. The mechanism of malperfusion can be difficult to identify on computed tomographic angiography (CTA). Real-time studies without radiation exposure or contrast, such as intravascular ultrasonography, allow evaluation of septal dynamics and flow during the cardiac cycle. Approximately 25% to 40% of acute TBAD cases are complicated by malperfusion or hemodynamic instability.10Fattori R. Montgomery D. Lovato L. Kische S. Di Eusanio M. Ince H. et al.Survival after endovascular therapy in patients with type B aortic dissection: a report from the International Registry of Acute Aortic Dissection (IRAD).JACC Cardiovasc Interv. 2013; 6: 876-882Crossref PubMed Scopus (303) Google Scholar In addition to rupture and malperfusion, other high-risk features of TBAD have been reported: refractory pain, refractory hypertension, bloody pleural effusion, aortic diameter >40 mm, readmission, malperfusion with only radiologic evidence, entry tear on the lesser curvature of the arch, and aortic false lumen diameter >22 mm.3Lombardi J.V. Hughes G.C. Appoo J.J. Bavaria J.E. Beck A.W. Cambria R.P. et al.Society for Vascular Surgery (SVS) and Society of Thoracic Surgeons (STS) reporting standards for type B aortic dissections.Ann Thorac Surg. 2020; 109: 959-981Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar The cornerstones of medical therapy for acute TBAD are anti-impulse therapy and pain control.11Hiratzka L.F. Bakris G.L. Beckman J.A. Bersin R.M. Carr V.F. Casey Jr., D.E. et al.2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine.J Am Coll Cardiol. 2010; 55: e27-e129Crossref PubMed Scopus (1089) Google Scholar According to the International Registry of Acute Aortic Dissection, over a 17-year period, the majority of patients were treated medically.12Pape L.A. Awais M. Woznicki E.M. Suzuki T. Trimarchi S. Evangelista A. et al.Presentation, diagnosis, and outcomes of acute aortic dissection: 17-year trends from the International Registry of Acute Aortic Dissection.J Am Coll Cardiol. 2015; 66: 350-358Crossref PubMed Scopus (638) Google Scholar In addition, the International Registry of Acute Aortic Dissection data showed that the use of beta blockers was associated with better outcomes in all patients who presented with dissection (acute type A and acute type B), and the use of calcium channel blockers was associated with longer survival in all patients with acute TBAD, including the ones treated medically.13Suzuki T. Isselbacher E.M. Nienaber C.A. Pyeritz R.E. Eagle K.A. Tsai T.T. et al.Type-selective benefits of medications in treatment of acute aortic dissection (from the International Registry of Acute Aortic Dissection [IRAD]).Am J Cardiol. 2012; 109: 122-127Abstract Full Text Full Text PDF PubMed Scopus (151) Google Scholar We prefer to administer esmolol, labetalol, or nicardipine. Other medications such as nitroprusside (a vasodilator) and clevidipine (a calcium channel blocker) have been also used.14Alviar C.L. Gutierrez A. Cho L. Krishnaswamy A. Saleh A. Lincoff M.A. et al.Clevidipine as a therapeutic and cost-effective alternative to sodium nitroprusside in patients with acute aortic syndromes.Eur Heart J Acute Cardiovasc Care. 2020; 9: S5-S12Crossref PubMed Google Scholar Our hemodynamic targets are a heart rate of <70 beats per minute and systolic blood pressure between 100 and 120 mm Hg. Refractory hypertension, as well as the need for systolic blood pressure >120 mm Hg for adequate vital organ perfusion in patients with severe chronic hypertension, usually prompts us to proceed with surgical intervention. There are important benefits of endovascular repair in acute cases. The objectives of TEVAR in patients with acute TBAD are to cover the primary entry tear, redirect flow to the true lumen, depressurize the false lumen, and resolve any malperfusion. The long-term objectives of TEVAR are remodeling of the dissected aorta, thrombosis of the false lumen, and avoiding future open or endovascular interventions. Various studies show a mortality, paraplegia, and stroke benefit for TEVAR versus open surgical repair.15Nienaber C.A. Kische S. Rousseau H. Eggebrecht H. Rehders T.C. Kundt G. et al.Endovascular repair of type B aortic dissection: long-term results of the randomized investigation of stent grafts in aortic dissection trial.Circ Cardiovasc Interv. 2013; 6: 407-416Crossref PubMed Scopus (724) Google Scholar, 16Moulakakis K.G. Mylonas S.N. Dalainas I. Kakisis J. Kotsis T. Liapis C.D. Management of complicated and uncomplicated acute type B dissection. A systematic review and meta-analysis.Ann Cardiothorac Surg. 2014; 3: 234-246PubMed Google Scholar, 17Eggebrecht H. Nienaber C.A. Neuhäuser M. Baumgart D. Kische S. Schmermund A. et al.Endovascular stent-graft placement in aortic dissection: a meta-analysis.Eur Heart J. 2006; 27: 489-498Crossref PubMed Scopus (465) Google Scholar, 18Fattori R. Tsai T.T. Myrmel T. Evangelista A. Cooper J.V. Trimarchi S. et al.Complicated acute type B dissection: Is surgery still the best option? A report from the International Registry of Acute Aortic Dissection.JACC Cardiovasc Interv. 2008; 1: 395-402Crossref PubMed Scopus (342) Google Scholar In patients with connective tissue disorders and malperfusion, endovascular repair is the first-line therapy; it can be a temporizing strategy for eventual open surgical repair.19Preventza O. Mohammed S. Cheong B.Y. Gonzalez L. Ouzounian M. Livesay J.J. et al.Endovascular therapy in patients with genetically triggered thoracic aortic disease: applications and short- and mid-term outcomes.Eur J Cardiothorac Surg. 2014; 46: 248-253Crossref PubMed Scopus (28) Google Scholar Open surgical repair is reserved for situations in which hostile anatomy makes endovascular repair technically infeasible.18Fattori R. Tsai T.T. Myrmel T. Evangelista A. Cooper J.V. Trimarchi S. et al.Complicated acute type B dissection: Is surgery still the best option? A report from the International Registry of Acute Aortic Dissection.JACC Cardiovasc Interv. 2008; 1: 395-402Crossref PubMed Scopus (342) Google Scholar,20Afifi R.O. Sandhu H.K. Leake S.S. Boutrous M.L. Kumar III, V. Azizzadeh A. et al.Outcomes of patients with acute Type B (DeBakey III) aortic dissection: a 13-year, single-center experience.Circulation. 2015; 132: 748-754Crossref PubMed Scopus (90) Google Scholar,21Appoo J.J. Bozinovski J. Chu M.W. El-Hamamsy I. Forbes T.L. Moon M. et al.Canadian Cardiovascular Society/Canadian Society of Cardiac Surgeons/Canadian Society for Vascular Surgery joint position statement on open and endovascular surgery for thoracic aortic disease.Can J Cardiol. 2016; 32: 703-713Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar The standard treatment approach for acute complicated TBAD, defined as impending rupture or clinical malperfusion, is to reduce morbidity and mortality risk with endovascular therapy. Complicated TBAD has an early mortality rate of 16% and a 5-year mortality of 40%.20Afifi R.O. Sandhu H.K. Leake S.S. Boutrous M.L. Kumar III, V. Azizzadeh A. et al.Outcomes of patients with acute Type B (DeBakey III) aortic dissection: a 13-year, single-center experience.Circulation. 2015; 132: 748-754Crossref PubMed Scopus (90) Google Scholar,22Ehrlich M.P. Rousseau H. Heijmen R. Piquet P. Beregi J.P. Nienaber C.A. et al.Midterm results after endovascular treatment of acute, complicated type B aortic dissection: the Talent Thoracic Registry.J Thorac Cardiovasc Surg. 2013; 145: 159-165Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar Endovascular therapy resulted in a 6.8% operative mortality rate, 6.8% stroke rate, 5.5% paraplegia/paraparesis rate, 6.8% rate of renal failure requiring dialysis, and 1.4% bowel ischemia rate in a prospective, nonrandomized single-arm, multicenter study examining acute complicated TBADs (Use of the Zenith Dissection Endovascular System in the Treatment of Patients With Acute, Complicated Type B Aortic Dissection [STABLE II]).23Lombardi J.V. Gleason T.G. Panneton J.M. Starnes B.W. Dake M.D. Haulon S. et al.STABLE II clinical trial on endovascular treatment of acute, complicated type B aortic dissection with a composite device design.J Vasc Surg. 2020; 71: 1077-1087.e2Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar At 1 year, there was favorable remodeling; almost all patients had partial or complete false lumen thrombosis. In our opinion, the term uncomplicated acute aortic dissection, which is often used in the literature, is misleading and unsuitable given the natural history and late complications of the disease. As a result, there is controversy regarding the need for and timing of intervention in patients with no clinical malperfusion or impending rupture. We do know that 60% of patients with acute uncomplicated TBAD have aneurysmal rupture or dilatation requiring surgical repair within 5 years of initial presentation,24Juvonen T. Ergin M.A. Galla J.D. Lansman S.L. McCullough J.N. Nguyen K. et al.Risk factors for rupture of chronic type B dissections.J Thorac Cardiovasc Surg. 1999; 117: 776-786Abstract Full Text Full Text PDF PubMed Scopus (167) Google Scholar, 25Schwartz S.I. Durham C. Clouse W.D. Patel V.I. Lancaster R.T. Cambria R.P. et al.Predictors of late aortic intervention in patients with medically treated type B aortic dissection.J Vasc Surg. 2018; 67: 78-84Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar, 26Durham C.A. Cambria R.P. Wang L.J. Ergul E.A. Aranson N.J. Patel V.I. et al.The natural history of medically managed acute type B aortic dissection.J Vasc Surg. 2015; 61: 1192-1198Abstract Full Text Full Text PDF PubMed Scopus (125) Google Scholar, 27Tsai T.T. Fattori R. Trimarchi S. Isselbacher E. Myrmel T. Evangelista A. et al.Long-term survival in patients presenting with type B acute aortic dissection: insights from the International Registry of Acute Aortic Dissection.Circulation. 2006; 114: 2226-2231Crossref PubMed Scopus (430) Google Scholar and that 25% to 30% of uncomplicated acute TBAD cases progress to a complicated state.28Reutersberg B. Trenner M. Haller B. Geisbüsch S. Reeps C. Eckstein H.H. The incidence of delayed complications in acute type B aortic dissections is underestimated.J Vasc Surg. 2018; 68: 356-363Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar Although the practice is not universal, there is a trend29Tadros R.O. Tang G.H.L. Barnes H.J. Mousavi I. Kovacic J.C. Faries P. et al.Optimal treatment of uncomplicated type B aortic dissection: JACC review topic of the week.J Am Coll Cardiol. 2019; 74: 1494-1504Crossref PubMed Scopus (66) Google Scholar toward using TEVAR to treat patients with uncomplicated acute TBAD but with substantial features and radiologic evidence of malperfusion. This is our preferred approach, as well. Nevertheless, it is important for us as surgeons to be specific and justify why and when we are to intervene in these patients. The 2-year Investigation of Stent Grafts in Aortic Dissection randomized trial and the 5-year Investigation of Stent Grafts in Aortic Dissection XL trial, which were performed in patients with subacute to chronic dissection (2-52 weeks) and not patients in the hyperacute or acute phase, medical and endovascular therapy together were associated with better 5-year aorta-specific survival and delayed progression of the disease than medical therapy alone.15Nienaber C.A. Kische S. Rousseau H. Eggebrecht H. Rehders T.C. Kundt G. et al.Endovascular repair of type B aortic dissection: long-term results of the randomized investigation of stent grafts in aortic dissection trial.Circ Cardiovasc Interv. 2013; 6: 407-416Crossref PubMed Scopus (724) Google Scholar The European aortic guidelines recommend that TEVAR be considered in uncomplicated TBAD (Class IIA, level of evidence: B).5Erbel R. Aboyans V. Boileau C. Bossone E. Bartolomeo R.D. Eggebrecht H. et al.2014 ESC guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC).Eur Heart J. 2014; 35: 2873-2926Crossref PubMed Scopus (2922) Google Scholar Regarding the timing of intervention, the Valiant Thoracic Stent Graft Evaluation for Treatment of Descending Thoracic Aortic Dissections registry found similar aortic remodeling between the acute phase (<15 days) and subacute phase (15-92 days) with less aortic remodeling in the chronic phase (>92 days).30VIRTUE Registry InvestigatorsMid-term outcomes and aortic remodelling after thoracic endovascular repair for acute, subacute, and chronic aortic dissection: the VIRTUE Registry.Eur J Vasc Endovasc Surg. 2014; 48: 363-371Abstract Full Text Full Text PDF PubMed Scopus (163) Google Scholar There were 2 instances of retrograde type A aortic dissection in the acute phase. Five-year data from 50 patients who were treated for acute complicated TBAD with the Valiant thoracic stent graft and the Captivia delivery system (Medtronic Inc, Santa Rosa, Calif) in a prospective nonrandomized dissection trial,31Bavaria J.E. Brinkman W.T. Hughes G.C. Shah A.S. Charlton-Ouw K.M. Azizzadeh A. et al.Five-year outcomes of endovascular repair of complicated acute type B aortic dissections.J Thorac Cardiovasc Surg. May 13, 2020; ([Epub ahead of print])Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar freedom from dissection-related mortality was 83%, and freedom from secondary procedures related to dissection was 86%. Positive aortic remodeling with a stable or decreased false lumen was seen in 77% of patients, and true-lumen diameter over the length of the stent graft increased or remained stable in 94%. Desai and colleagues32Desai N.D. Gottret J.P. Szeto W.Y. McCarthy F. Moeller P. Menon R. et al.Impact of timing on major complications after thoracic endovascular aortic repair for acute type B aortic dissection.J Thorac Cardiovasc Surg. 2015; 149: S151-S156Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar found that TEVAR had fewer complications when performed in the subacute phase (<42 days) than in the acute phase (<14 days). In particular, retrograde type A dissection was more common in the acute phase, and the authors and others have suggested that treatment during the subacute phase is optimal.32Desai N.D. Gottret J.P. Szeto W.Y. McCarthy F. Moeller P. Menon R. et al.Impact of timing on major complications after thoracic endovascular aortic repair for acute type B aortic dissection.J Thorac Cardiovasc Surg. 2015; 149: S151-S156Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar,33Clough R.E. Nienaber C.A. Evidence for and risks of endovascular treatment of asymptomatic acute type B aortic dissection.J Cardiovasc Surg (Torino). 2017; 58: 270-277PubMed Google Scholar We want to emphasize that the knowledge of wire and catheters and the skill set that is required to treat patients with aortic dissection is key for any interventionalist performing TEVAR to avoid periprocedural complications. The Acute Dissection: Stent Graft or Best Medical Therapy trial was a randomized trial of TEVAR versus optimal therapy in 61 patients with uncomplicated acute TBAD.34Brunkwall J. Kasprzak P. Verhoeven E. Heijmen R. Taylor P. Alric P. et al.Endovascular repair of acute uncomplicated aortic type B dissection promotes aortic remodelling: 1 year results of the ADSORB trial.Eur J Vasc Endovasc Surg. 2014; 48: 285-291Abstract Full Text Full Text PDF PubMed Scopus (252) Google Scholar The TEVAR group had greater aortic remodeling with false lumen thrombosis and reduction of false lumen diameter.34Brunkwall J. Kasprzak P. Verhoeven E. Heijmen R. Taylor P. Alric P. et al.Endovascular repair of acute uncomplicated aortic type B dissection promotes aortic remodelling: 1 year results of the ADSORB trial.Eur J Vasc Endovasc Surg. 2014; 48: 285-291Abstract Full Text Full Text PDF PubMed Scopus (252) Google Scholar Qin and colleagues35Qin Y.L. Wang F. Li T.X. Ding W. Deng G. Xie B. et al.Endovascular repair compared with medical management of patients with uncomplicated Type B acute aortic dissection.J Am Coll Cardiol. 2016; 67: 2835-2842Crossref PubMed Scopus (82) Google Scholar compared TEVAR and optimal medical therapy in a retrospective study of 338 patients with uncomplicated TBAD. The TEVAR group had fewer aortic-related adverse events, including rupture, aortic enlargement (>60 mm), retrograde type A aortic dissection, ulcer-like projection, endoleak, and stent graft-induced new entry (24% vs 38%).35Qin Y.L. Wang F. Li T.X. Ding W. Deng G. Xie B. et al.Endovascular repair compared with medical management of patients with uncomplicated Type B acute aortic dissection.J Am Coll Cardiol. 2016; 67: 2835-2842Crossref PubMed Scopus (82) Google Scholar The 5-year survival rate was higher in the TEVAR group (89% vs 86%).35Qin Y.L. Wang F. Li T.X. Ding W. Deng G. Xie B. et al.Endovascular repair compared with medi" @default.
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• W3157470475 date "2022-10-01" @default.
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• W3157470475 title "Medical or endovascular management of acute type B aortic dissection" @default.
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