Evolving Experience of Percutaneous Management of Type B Aortic Dissection

Abstract

Aortic dissection is a life-threatening condition characterised by high early mortality. While general consensus exists regarding the need of immediate surgical repair for patients with acute ascending aortic dissection, the optimal treatment strategy for type B aortic dissection continues to be a matter of debate. It has been generally advocated that patients who have type B aortic dissection without complications should be treated with medical therapy, historically based on the Wheat’s concept of antiimpulse therapy, decreasing the force of cardiac contraction and systolic blood pressure acting upon the weaker aortic wall. With aggressive antihypertensive therapy up to 85% of patients may survive their initial hospital stay. However, about 30% of acute type B dissections at clinical presentation are complicated by peripheral vascular ischemia or hemodynamic instability, which results in high risk of spontaneous death. The perception that prognosis of type B dissection is better with medical management mostly derives from the negative results for descending aorta surgery. Direct aortic replacement for acute aortic dissection showed significant mortality and paraplegia rate, even in the outstanding Crawford–Svennson data, reporting 30–36% of paraplegia for extensive aortic replacement for dissection. Long-term follow-up of patients with type B dissection showed unsatisfactory outcome even after successful initial stabilization and optimal medical therapy. Mortality is related either to retrograde progression of dissection with involvement of