Endovascular Repair Compared With Medical Management of Patients With Uncomplicated Type B Acute Aortic Dissection

Qin, Yuan; Wang, Feng; Li, Tianxiao; Ding, Wei; Deng, Gang; Xie, Bo; Teng, Gao‐Jun

doi:10.1016/j.jacc.2016.03.578

Cited by 112 publications

(152 citation statements)

References 35 publications

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“…Nevertheless, medical treatment is associated with a well-known risk of expansion of distal dissected segments, which occurs as a late complication in about 30-40% of patients (4,5). Preemptive management of so-called uncomplicated TBAD has recently been shown to prevent aneurysmal degeneration and impact positively on survival with a lower incidence of late complications by the induction of remodelling (5,6).…”

Section: Introductionmentioning

confidence: 99%

Conservative management versus endovascular or open surgery in the spectrum of type B aortic dissection

Yuan¹,

Mitsis²,

Ghonem³

et al. 2018

J. Vis. Surg.

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Background: Type B aortic dissection is a life-threatening acute aortic condition often with acute ischemic signs or symptoms. With initial management focusing on alleviating malperfusion and pain, and avoiding propagation of dissection or rupture both systolic blood and pulse pressure should be reduced initially by an aggressive medical approach. In the setting of persistent signs of complications endovascular strategies have replaced open surgery and led to a fourfold increase in early survival and better long-term outcomes. Results: Our manuscript has summarized data collected over 12 years on management specific outcomes in the setting of distal aortic dissection and provides an up-to-date interpretation of the published evidence.For complicated cases, treated acutely, the 30-day or in-hospital mortality was 7.3% when managed by endovascular means, whereas the pooled rate for 30-day or in-hospital mortality was 19.0% when subjected to open repair. For acute uncomplicated type B dissection usually treated with blood pressure lowering medications, the pooled 30-day or in-hospital mortality rate was 2.4%. Survival rates at 5 years averaged at 60% (40% mortality). Freedom from any aortic event ranged from 34.0% to 83.9%, underlining an inherent risk of progression and late complications. For chronic complicated type B dissection, the rates of stroke, paraplegia and operative mortality following endovascular repair ranged from 5% to 13%, 2% to 13% and 2 to 13%, respectively, while 5-year survival rates after open repair ranged from 60% to 90%. In chronic uncomplicated type B dissection almost 90% of patients survive initial hospitalization and were subjected to medical management with a 5-year survival of 50-80%. However, up to 20-55% of medically treated patients develop aneurysmal degeneration after 5 years with an unknown risk of rupture.Conclusions: Currently, the less invasive strategy of endovascular repair (as compared to open surgery) provides improved 30-day or in-hospital survival in the setting of complicated acute type B aortic dissection and may seek broad application. Open surgical aortic reconstruction should be left to experienced aortic centres if endovascular management is not an option.

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Section: Introductionmentioning

confidence: 99%

Conservative management versus endovascular or open surgery in the spectrum of type B aortic dissection

Yuan¹,

Mitsis²,

Ghonem³

et al. 2018

J. Vis. Surg.

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“…If in doubt, a connective tissue disorder should reliably be ruled out before considering prophylactic TEVAR.How do the present findings fit into the current strategic management of type B aortic dissection and how do these new data add value? A structured follow-up scheme (in any case of dissection) seems valuable considering the relatively high vascular event rate regardless of therapy(7). Further, the data confirmed a long-term benefit from TEVAR in "un-complicated" type B dissection and solidified the notion of prophylactic TEVAR.…”

mentioning

confidence: 60%

“…Thus, if a patient was expected to survive at least 5 years, the evidence suggested that early TEVAR offered an advantage over medical management alone. It should be noted that reported event rates in both groups appear high and underline the need for structured follow-up/surveillance of all patients with previous dissection.The work by Qin et al(7) would seem to confirm the recent swing to dismiss the term "uncomplicated dissection" and consider most, if not all, cases of type B dissection as "potentially complicated," because these patients' outcomes seem to improve long term as previously suggested from registries and the ran-…”

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confidence: 72%

“…The current paper by Qin et al (7) in this issue of the Journal offers some insight, although bear in mind the study is based on a chart review and retrospective analysis of data from 3 Chinese cardiovascular centers across a period of 11 years. They concluded that TEVAR is feasible for "uncompli- Third, whereas the overall observations favored TEVAR in "uncomplicated" dissection with long-term benefit (8,9), and seemed to support prophylactic TEVAR (thus, preventing late complications), the Finally, and in sync with our journey toward precision medicine (19), every patient regardless of management should be followed using a compulsory prospective registry for later granular analysis.…”

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confidence: 99%

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The Art of Stratifying Patients With Type B Aortic Dissection

Nienaber

2016

Journal of the American College of Cardiology

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“…Qin et al (1) reported a multi-institutional retrospective study involving three hospitals that analyzed and compared the effects of thoracic endovascular aortic repair (TEVAR) combined with best medical treatment (BMT) versus BMT alone for treating uncomplicated acute type B aortic dissection (TBAD). The controversy regarding the actual efficacy and benefits of TEVAR in uncomplicated acute TBAD is partly attributable to study reports based on analysis over a heterogeneous population of both complicated and uncomplicated TBAD patients (2).…”

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confidence: 99%

Treatment of uncomplicated acute type B aortic dissection in the endovascular era: is it time for a paradigm shift?

Choo

2017

J. Thorac. Dis.

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Qin et al.(1) reported a multi-institutional retrospective study involving three hospitals that analyzed and compared the effects of thoracic endovascular aortic repair (TEVAR) combined with best medical treatment (BMT) versus BMT alone for treating uncomplicated acute type B aortic dissection (TBAD). The controversy regarding the actual efficacy and benefits of TEVAR in uncomplicated acute TBAD is partly attributable to study reports based on analysis over a heterogeneous population of both complicated and uncomplicated TBAD patients (2). To address this issue, Qin et al. selectively included patients diagnosed with uncomplicated acute TBAD only. The results clearly showed a greater benefit of adding TEVAR to BMT over BMT alone. Currently, TEVAR is a class II recommendation for treating uncomplicated acute TBAD, while BMT remains a class I recommendation (3,4). The lower class of recommendation for TEVAR is mostly attributable to the lack of robust data to support its routine application. Currently, BMT appears to demonstrate relatively enhanced short-term outcomes. However, the early benefits do not seem to be sustained over time, as evidenced by the time-dependent occurrence of aneurysmal degeneration and rupture or disease progression. Up to 40% of patients reportedly undergo surgery after BMT, resulting in a relatively low overall 6-year interventionfree survival rate approximating 41% (5-7). Furthermore, the reported 3-, 5-, and 6-year mortality rates are also suboptimal at 22.4%, 27.9%, and 42%, respectively (7-9).In contrast to uncomplicated TBAD, TEVAR is a class I recommendation for complicated acute TBAD (3,4). Considering the relatively poor long-term outcomes of BMT alone and the encouraging results observed with TEVAR for complicated acute TBAD, it seems reasonable to expect improved outcomes with TEVAR added to BMT for this condition. The ADSORB trial was the only prospective, randomized clinical trial aimed at collecting level A evidence for treating uncomplicated acute TBAD with TEVAR (10). Although the 1-year analysis was too short to address some of the more long-term issues, and the relatively small cohort size was limiting for an adequate statistical power of analysis, the procedural safety and significantly enhanced outcomes in terms of greater, albeit incomplete, false lumen (FL) thrombosis, decrease in FL size, and increase in true lumen (TL) size supported adding TEVAR to BMT (10). Similar to the ADSORB trial, Qin et al.(1) conducted a multi-institutional but a retrospective study. Despite its limitations, the study involved a larger cohort of 338 patients in which 184 received TEVAR plus BMT and 154 received BMT alone. Furthermore, the follow-up duration was significantly longer at 11 years. Therefore, the major strengths of this study were in the greater statistical power of analysis and the ability to provide valuable information regarding the primary endpoints over a significantly longer period of time. In this study, BMT plus TEVAR showed significantly fewer overall all-cause aorta-...

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Endovascular Repair Compared With Medical Management of Patients With Uncomplicated Type B Acute Aortic Dissection

Abstract: This study confirmed the feasibility of TEVAR for uncomplicated type B aortic dissection in the acute setting with fewer aortic-related adverse events and a lower mortality rate compared with BMT.

Cited by 112 publications

References 35 publications

Conservative management versus endovascular or open surgery in the spectrum of type B aortic dissection

Conservative management versus endovascular or open surgery in the spectrum of type B aortic dissection

The Art of Stratifying Patients With Type B Aortic Dissection

Treatment of uncomplicated acute type B aortic dissection in the endovascular era: is it time for a paradigm shift?

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