Aortic dissection reconsidered: type, entry site, malperfusion classification adding clarity and enabling outcome prediction

Abstract

OBJECTIVES Aortic dissection is complex. Imaging and treatment modalities are evolving, demanding a more differentiated but pragmatic dissection classification. Our goal was to provide a new practical classification system including Type of dissection, location of the tear of the primary Entry and Malperfusion (TEM). METHODS We extended the Stanford dissection classification (A and B) by adding non-A non-B aortic dissection, the location of the primary entry tear (E) and malperfusion (M). A 0 was added if the primary entry tear was not visible; 1, if it was in the ascending aorta; 2, if it was in the arch; and 3, if it was in the descending aorta (E0, E1, E2, E3). We added 0 if malperfusion was absent; 1, if coronary arteries; 2, if supra-aortic vessels; and 3, if visceral/renal and/or a lower extremity was affected (M0, M1, M2, M3). Plus (+) was added if malperfusion was clinically present and minus (−) if it was a radiological finding. RESULTS The new classification system was analysed in 357 patients retrospectively; distribution was 59%, 31% and 10% for A, B and non-A non-B dissections. The in-hospital mortality rate was 16%, 5% and 8% (P = 0.01). Postoperative stroke occurred in 14%, 1% and 3% (P < 0.001). The in-hospital mortality rate was 22%, 14%, 40% and 0% in A E0, E1, E2 and E3 (P = 0.023), respectively. Two years after the onset of dissection, the lowest survival rate was observed in A, followed by non-A non-B and B (83 ± 3% vs 88 ± 6% vs 93 ± 3%; P = 0.019). CONCLUSIONS The new practical TEM aortic dissection classification system adds clarity regarding the extent of the disease process, enhances awareness of the disease mechanism, aids in decision-making regarding the extent of repair and helps in anticipating outcome.

Endovascular ascending aortic repair in type A dissection: A systematic review

“…We report a 30‐day mortality of 9% and a short‐term mortality of 16%. When compared to literature data on in‐hospital mortality for open surgical repair of TAAD, ranging between 16% and 20%, these results suggest that endovascular repair is an acceptable alternative for patients who are deemed unfit to undergo open surgical repair for type A dissection 2,54 . It is important to note that, similar to type B aortic dissection, acuity of disease in TAAD impacts both patient presentation and outcome 55 .…”

“…Patients presenting with subacute/chronic TAAD have better short‐ and long‐term survival rates when compared to acute TAAD patients 3 . Stroke incidence with endovascular treatment of TAAD of 6% was no higher than previous reports from arch TEVAR 56‐58 and open TAAD repair 4,54,59 …”

“…45 Endovascular reinterventions were performed for Type I endoleak (n = 3) 35,36 and severe AI (n = 1). 45 2,54 It is important to note that, similar to type B aortic dissection, acuity of disease in TAAD impacts both patient presentation and outcome. 55 Patients presenting with subacute/chronic TAAD have better short-and long-term survival rates when compared to acute TAAD patients.…”

“…3 Stroke incidence with endovascular treatment of TAAD of 6% was no higher than previous reports from arch TEVAR [56][57][58] and open TAAD repair. 4,54,59 Given the novelty of this procedure and the lack of long-term outcomes, there remain several topics of concern that must be adequately considered: patient selection, vascular access, stent graft design, and aortic valve involvement. These topics will be addressed below.…”

Non‐A non‐B aortic dissection: A literature review

“…When the dissection is limited to the aortic arch or can be described as a retrograde dissection arising from the descending aorta that extends into the arch and stops before the ascending aorta; these dissections are then termed as non‐A non‐B aortic dissections 4,11 . The Contemporary classifications such as the TEM (Type, Entry and Malperfusion) aortic dissection classification include non‐A non‐B dissections 12 …”