What is the optimal timing for thoracic endovascular aortic repair in uncomplicated Type B aortic dissection?

Abstract

Background Uncomplicated Stanford Type B aortic dissection (un‐TBAD) is characterized by a tear in the aorta distal to the left subclavian artery without ascending aorta and arch involvement. Optimized cardiovascular control (blood pressure and heart rate) is the current gold standard treatment according to current international guidelines. However, emerging evidence indicates that thoracic endovascular aortic repair (TEVAR) is both safe and effective in the treatment of un‐TBAD with improved long‐term survival outcomes in combination with optimal medical therapy (OMT) relative to OMT alone. However, the optimal timeframe for intervention is not entirely clarified. Aims This review critically addresses current state‐of‐the‐art comparing TEVAR with OMT and corresponding clinical outcomes for un‐TBAD based on timing of intervention. Methods We carried out a comprehensive literature search on multiple electronic databases including PUBMED and Scopus to collate all research evidence on timing of TEVAR in uncomplicated Type B aortic dissection. Results TEVAR has proven to be a safe and effective treatment for un‐TBAD in combination with OMT through comparable survival outcomes, improved aortic remodeling, and relatively low periprocedural added risks. Though the timing of intervention remains controversial, it is becoming clear that performing TEVAR during the subacute phase of un‐TBAD yields better outcomes compared to earlier and delayed (>90 days) intervention. Conclusions Further research is required into both short‐ and long‐term outcomes of TEVAR in addition to its optimal therapeutic window for un‐TBAD. With stronger evidence, TEVAR is likely to be adopted as the gold‐standard intervention for un‐TBAD with definitive timeframe guidelines.

Mid‐ and long‐term outcomes of thoracic endovascular aortic repair in acute and subacute uncomplicated type B aortic dissection

“…A significant number of un‐TBAD patients on OMT alone, may require further complex intervention with TEVAR due to the progression of the dissection. Currently, only un‐TBAD patients who meet certain criteria making them “high‐risk” for aorta‐related complications without immediate risk of rupture or malperfusion are offered pre‐emptive TEVAR 4 . These high‐risk criteria are an initial aortic diameter of >40 mm, an entry tear >10 mm, an associated FL diameter of >22 mm, and a free‐floating TL 5,61 .…”

“…Several trials and observational studies have investigated the use of thoracic endovascular aortic repair (TEVAR) for un‐TBAD in an effort to shift the paradigm), but there are certain high‐risk features which may need be considered if a stent graft is an option 4 . These were summed up nicely in a recent interesting review by Jubouri et al 4 who combined the evidence from these studies, including the INSTEAD, INSTEAD‐XL, and ADSORB trials, as well as multiple retrospective studies. All of these which proved the TEVAR does offer a long‐term survival advantage and improved aortic remodeling in un‐TBAD patients relative to OMT alone.…”

“…Un‐TBAD is managed conventionally with optimal medical therapy (OMT), also known as best medical therapy (BMT), to strictly regulate the heart rate (<60 bpm) and blood pressure (BP) (systolic BP < 100–120 mmHg) 4,5 . However, un‐TBAD patients who are discharged with OMT alone maybe lost to follow‐up and the disease progresses to become fatal.…”

“…Some survival analyses showed that up to 50% of un‐TBAD patients on OMT alone were dead by 5 years 5 . Several trials and observational studies have investigated the use of thoracic endovascular aortic repair (TEVAR) for un‐TBAD in an effort to shift the paradigm), but there are certain high‐risk features which may need be considered if a stent graft is an option 4 . These were summed up nicely in a recent interesting review by Jubouri et al 4 who combined the evidence from these studies, including the INSTEAD, INSTEAD‐XL, and ADSORB trials, as well as multiple retrospective studies.…”

“…a recent interesting review by Jubouri et al 4 who combined the evidence from these studies, including the INSTEAD, INSTEAD-XL, and ADSORB trials, as well as multiple retrospective studies. All of these which proved the TEVAR does offer a long-term survival advantage and improved aortic remodeling in un-TBAD patients relative to OMT alone.…”