SUNDAY trial insights: questionnaire of clinical perspectives on medical therapy in uncomplicated type B aortic dissections.

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

Editors' Commentary

Commentary: Predicting adverse prognosis in chronic type B dissection: Are we there yet?

Cardiovascular disease is the leading cause of death in most Western societies and is increasing steadily in many developing countries. Aortic diseases constitute an emerging share of the burden. New diagnostic imaging modalities, longer life expectancy in general, longer exposure to elevated blood pressure, and the proliferation of modern noninvasive imaging modalities have all contributed to the growing awareness of acute and chronic aortic syndromes. Despite recent progress in recognition of both the epidemiological problem and diagnostic and therapeutic advances, the cardiology community and the medical community in general are far from comfortable in understanding the spectrum of aortic syndromes and defining an optimal pathway to manage aortic diseases.1–13 This comprehensive review is organized in two parts, with a focus on the etiology, natural history, and classification (with vascular staging) of aortic wall disease in Part I and emphasis on therapeutic management and follow-up in Part II. Both parts may help to better integrate the complexities of acute aortic syndromes.

Evolving Experience of Percutaneous Management of Type B Aortic Dissection

Endovascular treatment of complicated versus uncomplicated acute type B aortic dissection

Prognostic significance of early aortic remodeling in acute uncomplicated type B aortic dissection and intramural hematoma: Tell us what to do

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

Thoracic endovascular aneurysm repair for uncomplicated type B dissection

Endografts for Aortic Dissection

Update on the Diagnosis and Management of Inherited Aortopathies, Including Marfan Syndrome.

Objectives: Uncomplicated type B aortic dissection is generally treated with medical management including antihypertensive therapy. The purpose of this study is to investigate risk factors associated with the aortic enlargement in medically treated patients.Methods: Between July 2004 and April 2016, 127 consecutive patients with acute type B aortic dissection were treated in our institution. Of these, 104 patients diagnosed with uncomplicated type B dissection were managed medically as an initial treatment. According to the diameter of the dissected aorta, these patients were retrospectively placed into 2 groups: 1) enlargement group (group E: n=36); and 2) unchanged group (group U: n=68).Results: There was statistically significant difference regarding the initial diameter of the dissected aorta (group E: 42±7 mm, group U: 36±7 mm) (p<0.01). As regards the aneurysm growth rate, a significant difference between both groups was noted (group E: 10±32 mm/half-year, group U −3±19 mm/half-year) (p<0.05). In all 104 patients, 42 patients (40.4%) had patent false lumen with the average number of 1.5 intimal tears. Multivariate analysis showed the relationship for aortic enlargement were patent false lumen (p<0.05, 95%CI 0.407–0.935) and initial aortic diameter (p<0.01, 95%CI 1.076–1.158). Aortic event free survival (1/5/10 years) was 100/86/77% in group E and 92/79/79% in group U, respectively no differences between two groups (p=0.747).Conclusions: The medically managed patients with uncomplicated chronic type B dissection showed excellent survival rate during long-term follow-up. The results of surgical or endovascular treatment in patients underwent initial medical therapy were also satisfactory. The patent false lumen and aortic diameter at the onset may impact on aortic enlargement. Considering our results, the feasibility of elective endovascular repairs in stable dissection remains controversial even in the endovascular era. (This is a translation of Jpn J Vasc Surg 2018; 27: 55–60.)

Type A aortic dissection is a surgical emergency with mortality approaching 60 % when treated with medical therapy alone. Survival benefit has been consistently demonstrated with emergent surgical repair; however, overall mortality is still reported to be as high as 25 %. Type A aortic dissection most commonly arises from a primary intimal tear just distal to the coronary ostia, followed by primary aortic arch tear. Less commonly, retrograde type A dissection (RTAD) can arise from a primary intimal tear in the descending aorta with retrograde propagation into the ascending aorta. RTAD are categorized as spontaneous or iatrogenic. Spontaneous RTAD account for approximately 10 % of all acute type A dissections. Iatrogenic RTAD have become a topic of increased interest due to their occurrence after thoracic endovascular aortic repair (TEVAR) for type B descending thoracic aortic (DTA) dissections and aneurysms. In addition, open surgical repair of RTAD carries increased perioperative morbidity and mortality due to the necessity of replacing the aortic arch in order to cover the primary dissection flap. Some clinicians have advocated treating RTAD in a similar fashion to type B dissection where the mainstay of treatment is medical management with or without TEVAR. Studies comparing medical and surgical therapies have demonstrated improved medium term outcomes RTAD compared to antegrade dissections. The studies suggest that medical management may be suitable in select patients who have (1) no malperfusion syndromes, (2) false lumen thrombosis, (3) no aneurysmal disease, and (4) no rupture. No long term data is available comparing retrograde versus antegrade aortic dissection, thus, the true natural history is unclear. In this report, we review the current literature on the management strategies of RTAD and provide our institutional approach in treating this complex aortic pathology

A type B dissection involves the aorta distal to the subclavian artery, and accounts for 25-40% of aortic dissections. Approximately 75% of these are uncomplicated with no malperfusion or ischemia. Multiple consensus statements recommend thoracic endovascular aortic repair (TEVAR) as the treatment of choice for acute complicated type B aortic dissections, while uncomplicated type B dissections are traditionally treated with medical management alone, including strict blood pressure control, as open repairs have a prohibitively high morbidity of up to 31%. However, with medical treatment alone, the morbidity, including aneurysm degeneration of the affected segment, is 30%, and mortality is 10% over 5 years. For both chronic and acute uncomplicated type B aortic dissections, emerging evidence supports the use of both best medical therapy and TEVAR. This paper reviews the current diagnosis and treatment of uncomplicated type B aortic dissections.

Optimal medical management is the primary treatment for patients presenting with acute uncomplicated type B aortic dissection [1]. One of the foremost aims is to reduce shear stress on the aorta by reducing overall blood pressure. However, quite some lack of knowledge hides behind the term optimal. In fact, the use of what sort of antihypertensive drug in whatever combination remains mostly unknown. In addition, some studies suggest protective effects of statin therapy as an additional medical treatment in patients with aortic disease, but the effects on patients with aortic dissection remain unclear [1]. Lastly, there remains an overall lack of data regarding the use of oral anticoagulants in patients with aortic dissection [2]. In this issue of the Journal, Jesse et al. [2] helped to close one of the many knowledge gaps we have regarding optimal medical management in patients with uncomplicated type B aortic dissections and need to be commended for conducting the ORCA study. In this unique study, the authors took advantage of a prior standardized approach to the medical management of patients with uncomplicated type B aortic dissections namely oral anticoagulation. The rationale was a fear of complete false lumen thrombosis potentially causing reno-visceral and/or iliac artery malperfusion as well as reno-visceral hypertension [3]. ORCA is clearly able to show no difference in patients with or without oral anticoagulation and branch vessel ischaemia but shows a significant risk for aortic interventions in patients receiving oral anticoagulation. While other studies have identified radiographic risk factors for aortic interventions, ORCA is one of the few studies investigating the influence of selective medical treatment [2, 4]. The combination of medical, clinical, and radiographic may help to further identify patient cohorts at risk for negative aortic remodelling.