contemporary management of acute type b aortic dissections

Contemporary Management of Acute Type B Aortic Dissections

Hiranya A. Rajasinghe MDThe Vascular Group of Naples, PLCNaples, Florida

DISSECTION TYPES

Type A Type B

PATHOGENESIS

TYPE A Ao DISSECTION

TYPE B Ao DISSECTION

ACUTE TYPE B AORTIC DISSECTION

25-40 % of all dissections

• 80 % (uncomplicated), preferred management is medical Rx

• 15 -20% (complicated): rupture, malperfusion, refractory medical therapy/HTN – consider surgical or endovascular Rx

International Registry of Aortic Dissection (IRAD)

International Registry of Aortic Dissection (IRAD)

International Registry of Aortic Dissection (IRAD)

Uncomplicated TBAD: Does it Exist?

Endovascular Repair of Type B Aortic Dissection

by Christoph A. Nienaber, Stephan Kische, Hervé Rousseau, Holger Eggebrecht, Tim C. Rehders, Guenther Kundt, Aenne Glass, Dierk Scheinert, Martin Czerny, Tilo Kleinfeldt, Burkhart Zipfel, Louis Labrousse, Rossella Fattori, and Hüseyin Ince

Circ Cardiovasc IntervVolume 6(4):407-416

August 20, 2013

Copyright © American Heart Association, Inc. All rights reserved.

Illustration demonstrating typical features of type B dissection with flow in both the true and the expanded false lumen resulting from a major proximal entry tear (left).

Christoph A. Nienaber et al. Circ Cardiovasc Interv. 2013;6:407-416

A, Kaplan–Meier estimates of all-cause mortality (death) and Landmark analysis with a breakpoint at 24 months after randomization to the end of the trial are shown for optimal

medical treatment (OMT) and OMT + thoracic endovascular aortic repair (TEVAR) groups.

Gadolinium-enhanced sagittal MR angiogram of type B dissection before randomization (top) and 5 years after endovascular repair (bottom).

Christoph A. Nienaber et al. Circ Cardiovasc Interv. 2013;6:407-416

TEVAR FOR AORTIC DISSECTIONPREVENTS LATE EXPANSION; ENCOURAGES AORTIC

REMODELING

All-Cause Mortality p=0.13

Aorta-Specific Mortality p=0.04

Disease Progression p=0.040%

10%

20%

30%

40%

50% OMT n=68

TEVAR+OMT n=72

Cumulative Clinical Results: Year 0 through Year 5

19.3% 19.3%

46.1%

11.1%

27.0%

19.1%Absolute Risk

Reduction

12.4%Absolute Risk

Reduction

6.9%

High-Risk Uncomplicated Acute TBAD Uncertainty remains regarding optimal management strategy

for high-risk uncomplicated acute TBAD

Consideration of early intervention appears reasonable in following scenarios:• Initial aortic diameter ≥ 4.0cm with patent false lumen• ≥ 22mm false lumen in proximal DTA• Recurrent/refractory pain or HTN• Partially thrombosed false lumen• Proximal entry tear ≥ 10mm• Entry tear on inner curve

Well-designed, prospective, randomized trial needed