Criteria for endovascular intervention in type B aortic dissection

Abstract

Background The use of thoracic endovascular aortic repair (TEVAR) for the management of uncomplicated type B aortic dissection (un‐TBAD) remains controversial. There is a lack of consensus over whether pre‐emptive TEVAR should be carried out in patients with un‐TBAD at risk of progression to complicated TBAD. We present a review of current evidence and seek to suggest criteria where endovascular intervention in un‐TBAD may prove beneficial relative to pharmacotherapy alone. Methods and materials PubMed and Cochrane databases were searched using terms including: type B aortic dissection, risk factors, medical therapy, TEVAR, false lumen (FL) expansion, and mortality. Papers were selected based on title and abstract. Results Optimal medical therapy remains the mainstay treatment for patients with un‐TBAD, however, patients with un‐TBAD present with varying degrees of disease progression risk. Factors such as age, aortic morphology, history of connective tissue disorders, FL thrombosis, and aortic branch involvement may potentiate progression from un‐TBAD to complicated TBAD. Short‐ and long‐term outcomes associated with TEVAR for TBAD remain promising. Conclusion Pre‐emptive TEVAR may be beneficial in patients with un‐TBAD presenting with the above factors, however, further prospective research into the optimal timing for TEVAR in un‐TBAD is required.

RELAYTM Branched–International Results of Vessel Patency and Reintervention

“…Decision making in these situations requires thorough planning and more evidence-based algorithm development to help ensure the correct therapeutic route is selected for patients. Risk factors for new dissection include patient age, prior interventions, and progression of vessel wall pathology ( 12 ). These factors can severely worsen a patient's condition and may result in the formation of a new tear and are very rarely associated with TEVAR or placement of a stent ( 5 , 9 ).…”

The misnomer of uncomplicated type B aortic dissection

“…There is evidence that remodeling is most effective in the subacute phase (15-30 days), and if a TBAD is considered for intervention, then it should be performed within the initial 90 days since symptom onset. 16,17 Jubouri et al 18 recently highlighted the evidence in the literature on the mid-and long-term clinical outcomes of TEVAR in UnCoTBAD, demonstrating its superiority to OMT. 19 The first group was OMT and TEVAR while the second group was OMT alone with the primary outcome measure being 2-year mortality rates.…”

“…Those who have intractable hypertension or ongoing pain following presentation may also benefit from early TEVAR. 17,28 It raises the question on whether these patients should be classified as CoTBAD despite no evidence of rupture or malperfusion. According to the IRAD registry, there is evidence that the presence of hypertension or refractory pain in a UnCoTBAD is associated with an increased mortality rate.…”

“…It is important to realize the reason for intervention in acute TBAD is to treat the long‐term consequences of a pressurized FL. There is evidence that remodeling is most effective in the subacute phase (15–30 days), and if a TBAD is considered for intervention, then it should be performed within the initial 90 days since symptom onset 16,17 . Jubouri et al 18 recently highlighted the evidence in the literature on the mid‐ and long‐term clinical outcomes of TEVAR in UnCoTBAD, demonstrating its superiority to OMT.…”

“…Other “high‐risk” symptoms and signs to evaluate include a primary entry tear >10 mm located on the arch concavity, total aortic diameter >40 mm and an associated FL diameter of >22 mm. Those who have intractable hypertension or ongoing pain following presentation may also benefit from early TEVAR 17,28 . It raises the question on whether these patients should be classified as CoTBAD despite no evidence of rupture or malperfusion.…”