Predictors of aortic growth in uncomplicated type B aortic dissection

Bogerijen, Guido H.W. van; Tolenaar, Jip L.; Rampoldi, Vincenzo; Moll, Frans L.; Herwaarden, Joost A. van; Jonker, Frederik H.W.; Eagle, Kim A.; Trimarchi, Santi

doi:10.1016/j.jvs.2014.01.042

Cited by 147 publications

(84 citation statements)

References 46 publications

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“…For patients with uncomplicated TBAD, effective blood pressure lowering medication is widely accepted as the standard initial management, together with consideration for endovascular repair. However, up 20-55% of medically treated patients may develop aneurysmal degeneration after 5 years (5,33,39,40,(86)(87)(88)(89) attributed to incomplete aortic remodelling. The concept of post-dissection aortic remodelling is important since a large entry tear, the location of it, true versus false lumen ratio and the amount of false lumen flow have a negative impact on prognosis (89)(90).…”

Section: Open Surgerymentioning

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: Open Surgerymentioning

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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“…Tight heart rate and blood pressure control, calcium-channel blockers, angiotensin receptor blockers, and statins have been associated with reduced aortic growth and complications. 44,50,[52][53][54][55] However, large clinical trials are still warranted to evaluate the long-term efficacy of these medical treatments for TBAD. For TBAD patients with Marfan syndrome, β-blockers remain the first line therapy, but angiotensin receptor blockers specifically appear to reduce aortic growth in this cohort.…”

Section: Optimal Medical Treatment (Omt)mentioning

confidence: 99%

“…Heart rate and blood pressure control 8,21,45,57 Blood pressure <140/90 mmHg or systolic <120 mmHg β-Blockers, calcium-channel blockers, angiotensin receptor blockers Alternatives: α1-adrenergic and non-specific β-blockers Aortic expansion and complications 50,[52][53][54][55] Reduce expansion and complications over time Calcium-channel blockers, angiotensin receptor blockers, and statins a In case of persistent hypotension, surgical intervention should be considered. IV, intravenous; MAP, mean arterial pressure.…”

Section: Chronic Treatmentmentioning

confidence: 99%

Update in the management of type B aortic dissection

et al. 2016

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Stanford type B aortic dissection (TBAD) is a life-threatening aortic disease. The initial management goal is to prevent aortic rupture, propagation of the dissection, and symptoms by reducing the heart rate and blood pressure. Uncomplicated TBAD patients require prompt medical management to prevent aortic dilatation or rupture during subsequent follow-up. Complicated TBAD patients require immediate invasive management to prevent death or injury caused by rupture or malperfusion. Recent developments in diagnosis and management have reduced mortality related to TBAD considerably. In particular, the introduction of thoracic stent-grafts has shifted the management from surgical to endovascular repair, contributing to a fourfold increase in early survival in complicated TBAD. Furthermore, endovascular repair is now considered in some uncomplicated TBAD patients in addition to optimal medical therapy. For more challenging aortic dissection patients with involvement of the aortic arch, hybrid approaches, combining open and endovascular repair, have had promising results. Regardless of the chosen management strategy, strict antihypertensive control should be administered to all TBAD patients in addition to close imaging surveillance. Future developments in stent-graft design, medical therapy, surgical and hybrid techniques, imaging, and genetic screening may improve the outcomes of TBAD patients even further. We present a comprehensive review of the recommended management strategy based on current evidence in the literature.

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“…75 Owing to a significantly lower risk of fatal aortic rupture and the high morbidity and mortality associated with operative repair of the descending aorta, medical management alone is advocated for uncomplicated Type B dissection with a reported 30-day mortality of 10%. 35,76 A number of factors have been associated with a greater risk of aortic dilation and adverse outcomes in patients treated conservatively for uncomplicated Type B aortic dissections (Table 4). [76][77][78][79] Patients who develop complications, including disease progression, contained rupture, and renal and mesenteric ischaemia often require more invasive management.…”

Section: Acute Aortic Syndrome Risk Factors and Clinical Presentationmentioning

confidence: 99%

“…35,76 A number of factors have been associated with a greater risk of aortic dilation and adverse outcomes in patients treated conservatively for uncomplicated Type B aortic dissections (Table 4). [76][77][78][79] Patients who develop complications, including disease progression, contained rupture, and renal and mesenteric ischaemia often require more invasive management. 35,36,80 However, patients who undergo surgery for these indications have a high rate of morbidity with a reported risk of paraplegia of 19% and mortality of 31%.…”

Section: Acute Aortic Syndrome Risk Factors and Clinical Presentationmentioning

confidence: 99%

The role of multidetector-row CT in the diagnosis, classification and management of acute aortic syndrome

Abbas¹,

Brown²,

Peebles³

et al. 2014

BJR

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The term "acute aortic syndrome" (AAS) encompasses several non-traumatic life-threatening pathologies of the thoracic aorta presenting in patients with a similar clinical profile. These include aortic dissection, intramural haematoma and penetrating atherosclerotic ulcers. These different pathological entities can be indistinguishable on clinical grounds alone and may be confused with other causes of chest pain, including myocardial infarction. Multidetector-row CT (MDCT) is the current modality of choice for imaging AAS with a sensitivity and specificity approaching 100%. Early diagnosis and accurate radiological classification is associated with improved clinical outcomes in AAS. We review the characteristic radiological features of the different pathologies that encompass AAS and highlight the vital role of MDCT in determining the management of these life-threatening conditions.

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Predictors of aortic growth in uncomplicated type B aortic dissection

Abstract: Several predictors might be used to identify those ABAD patients at high risk for aortic growth. Although conservative management remains indicated in uncomplicated ABAD, these patients might benefit from closer follow-up or early endovascular intervention.

Cited by 147 publications

References 46 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

Update in the management of type B aortic dissection

The role of multidetector-row CT in the diagnosis, classification and management of acute aortic syndrome

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