Readmission after early thoracic endovascular aortic repair versus medical management of acute type B aortic dissection

Commentary: Delaying the inevitable? Interventions for medically managed, uncomplicated type B aortic dissection.

Commentary: The secret life of aortic dissections

Early Thoracic Endovascular Aortic Repair for Acute Type B Dissection Is Associated with Increased Complications: Results from the Gore Global Registry for Endovascular Aortic Treatment Registry.

Knowledge gaps in surgical management for aortic dissection

Effect of Thoracic Endovascular Aortic Repair on Aortic Remodeling in Patients with Type B Aortic Dissection in an Asian Population

The management of acute type B aortic dissection (TBAD) has largely been dictated by whether or not the case is “complicated,” meaning symptomatic or extensive such that no intervention would lead to death. Historically, complicated acute TBAD has been managed with operative intervention and uncomplicated acute TBAD has been managed with medical treatment. Acute complicated TBAD left untreated has mortality rates as high as 50 % in the first month. While uncomplicated acute TBAD has good outcomes with medical management in the short-term, long-term outcomes are discouraging with mortality rates approaching 30–50 % at 5 years, largely due to aneurysmal degeneration of the false lumen. Both open and endovascular treatment strategies have a role in both complicated and uncomplicated acute TBAD and the role of endovascular intervention is ever-expanding as research shows favorable short-term outcomes and long-term aortic remodeling.

Thoracic endovascular aortic repair (TEVAR) for acute uncomplicated type B aortic dissection (TBAD) remains controversial. This study aims to evaluate the impact of TEVAR on mortality, morbidity, length of stay (LOS), and discharge status in patients with acute uncomplicated TBAD. We analyzed the National Inpatient Sample from 2009 and 2010. Patients were categorized according to the type of treatment: TEVAR or medical management. Outcomes, including mortality, stroke, myocardial infarction (MI), acute renal failure, discharge disposition, and LOS, were compared between the treatment groups. We identified 4706 patients with TBAD. Mean age was 67 years and 55% were male. Treatment options included TEVAR in 504 and medical management in 4202. The overall adjusted in-hospital mortality was similar for both the groups (8.5% for TEVAR vs 10.3% for medical management, P = .224). The TEVAR carried higher risk of stroke (odds ratio [OR] = 1.61, 95% confidence interval [CI] = [1.14-2.27]; P = .0073). The TEVAR was associated with prolonged LOS (12 vs 5.6 days, P < .0001) and patients were less likely to be discharged home (OR 0.73, 95% CI 0.54-0.99; P = .013). When stratified by age, all outcomes were similar between the 2 groups, with the exception of longer LOS with TEVAR. Thoracic endovascular aortic repair for acute uncomplicated TBAD was associated with similar in-hospital mortality, MI, and renal failure as compared to medical management. The TEVAR had higher rate of stroke up to the age 70 years and longer LOS. Because extending TEVAR to less complicated patients could only decrease TEVAR mortality rates, these findings support the more widespread use of TEVAR to treat patients with uncomplicated TBAD.

Stanford type B aortic dissection (TBAD) is a life-threatening disease. Current therapeutic guidelines recommend medical therapy with aggressive blood pressure lowering for patients with acute TBAD unless they have fatal complications. Although patients with uncomplicated TBAD have relatively low early mortality, aorta-related adverse events during the chronic phase worsen the long-term clinical outcome. Recent advances in thoracic endovascular aortic repair (TEVAR) can improve clinical outcomes in patients with both complicated and uncomplicated TBAD. According to present guidelines, complicated TBAD patients are recommended for TEVAR. However, the indication in uncomplicated TBAD remains controversial. Recent results of randomized trials, which compared the clinical outcome in patients treated with optimal medical therapy and those treated with TEVAR, suggest that preemptive TEVAR should be considered in uncomplicated TBAD with suitable aortic anatomy. However, these trials failed to show improvement in early mortality in patients treated with TEVAR compared with patients treated with optimal medical therapy, which suggest the importance of patient selection for TEVAR. Several clinical and imaging-related risk factors have been shown to be associated with early disease progression. Preemptive TEVAR might be beneficial and should be considered for high-risk patients with uncomplicated TBAD. However, an interdisciplinary consensus has not been established for the definition of patients at high-risk of TBAD, and it should be confirmed by experts including physicians, radiologists, interventionalists, and vascular surgeons. This review summarizes the current understanding of the therapeutic strategy in patients with TBAD based on evidence and expert consensus.

Thoracic Endovascular Aortic Repair on Zone 2 Landing for Type B Aortic Dissection

Predictors of late aortic intervention in patients with medically treated type B aortic dissection

Outcomes from the Gore Global Registry for Endovascular Aortic Treatment in patients undergoing thoracic endovascular aortic repair for type B dissection

Part One: For the Motion. Level 1 Evidence is Necessary Comparing TEVAR and Medical Management of Uncomplicated Type B Aortic Dissection

Beta-blocker use after thoracic endovascular aortic repair in patients with type B aortic dissection is associated with improved early aortic remodeling.

To evaluate the clinical outcomes and aortic remodelling rates following thoracic endovascular aortic repair (TEVAR) for acute or subacute type B aortic dissection (TBAD) based on technique. All TEVARs for acute/subacute TBAD between 01/01/2008 and 01/06/2020 were included. TEVARS were grouped by technique (TEVAR only, PETTICOAT and STABILISE). Aortic remodelling was assessed at three aortic levels on follow-up CT. Thirty-day technical/clinical success rates, re-intervention rates and complications were recorded. A total of 29 patients were included. The median age was 55years (31-82). The median duration from initial presentation to TEVAR was 7days (0-84). Intra-procedural complications included one aortic rupture from balloon moulding in a STABILISE case. Thirty-day mortality, stroke, spinal cord ischaemia and visceral ischaemia were 3% (n = 1), 3% (n = 1), 3% (n = 1) and 3% (n = 1), respectively. (All occurred in acute TBAD.) Overall survival was 50.5months (18-115). Median follow-up was 31months (1-115). Six patients (21%) required re-intervention, with a median time of 5months (5-46) from first TEVAR. Overall complete aortic remodelling rates were: 89% at the proximal descending thoracic aorta, 78% at the distal thoracic aorta and 50% at the infra-renal abdominal aorta. At the infra-renal aorta, the STABILISE group (n = 11) had a higher complete aortic remodelling rate (82%) compared to TEVAR alone (n = 12) (20%). Endovascular intervention for acute and subacute TBAD is safe with a high rate of technical success. STABILISE results in higher aortic remodelling at the infra-renal aorta (82%) compared to TEVAR alone (20%) but risks aortic rupture from balloon moulding.

ObjectiveFalse lumen expansion is a major factor that determines long-term survival of uncomplicated type B aortic dissection (TBAD). The objective of this study was to investigate whether structural wall stress distributions computed from patient-specific acute TBAD geometries can be used to predict aortic growth rates.MethodsThree-dimensional (3D) computed tomography angiography (CTA) of 9 patients with acute uncomplicated TBAD were obtained at initial hospital admission and at their most recent follow-up visits. Patient-specific structural wall stress distributions were computed from the initial baseline CTA using a forward penalty method. Spatially varying blood pressure distributions, derived from computational fluid dynamics (CFD) simulations informed by patient-specific transthoracic echocardiography (TTE) and blood pressure (BP) measurements, were incorporated into the forward penalty stress analysis. Aortic growth rates were quantified and visualized within the 3D TBAD geometries using the initial baseline and follow-up scans. Linear mixed-effects regression analyses were performed to evaluate the spatial correlations between biomechanical markers (structural wall stress, wall shear stress, and pressure) and aortic growth rates.ResultsUtilizing initial baseline CTA, TTE, and BP data, the forward penalty analyses revealed hemodynamic and structural mechanics insights of acute uncomplicated TBADs. The linear mixed-effects model indicated that the fixed-effect association between structural wall stress and aortic growth rate distributions was statistically significant (p=0.039), which demonstrated that aortic segments experiencing high wall stress exhibited rapid growth. Fixed-effect associations were not significant when predicting growth rate using wall shear stress (p=0.86) or pressure (p=0.61) distributions. Significant Pearson correlation coefficients (p<0.05) were observed between structural wall stress and aortic growth rate in all patients.ConclusionHigh structural wall stress was associated with regions of high aortic growth rates, while false lumen thrombosis was associated with low wall stress. Structural wall stress derived from the forward penalty approach may be a novel predictor of aortic growth rate and failure of optimal medical therapy in acute TBAD.