TEVAR in TBAD with high-risk features? Not so quickly!!!

Abstract

For decades, the vascular community has debated the concept of vulnerable plaque to predict the risk of a devastating stroke in patients with asymptomatic carotid disease. It was, at times, rigorous and generated high-quality publications and led, in part, to randomized trials and nested registries. The term high-risk features (HRFs) has gained more credibility after the publication of the reporting standards from the Society for Vascular Surgery (SVS)-Society of Thoracic Surgeons (STS).1Lombardi J.V. Hughes G.C. Appoo J.J. Bavaria J.E. Beck A.W. Cambria R.P. et al.Society for Vascular Surgery (SVS) and Society of Thoracic Surgeons (STS) reporting standards for type B aortic dissections.J Vasc Surg. 2020; 71: 723-747Abstract Full Text Full Text PDF PubMed Scopus (165) Google Scholar It would make sense to offer a preemptive thoracic endovascular aneurysm repair (TEVAR) in patients with HRFs in the hope of avoiding an open thoracoabdominal aortic aneurysm repair and its impact on patients and their families. However, somehow, we skipped the rigorous debate. We easily traded evidence for “common sense.” Except for one feature (aortic diameter of >40 mm), none have been validated prospectively or replicated in large case series. The combined SVS-STS committee used a single paper with mixed data and incomplete follow-up to justify adding persistent pain and hypertension to the list of HRFs, which might explain the boom of unnecessary TEVAR for uncomplicated type B aortic dissection.2Trimarchi S. Eagle K.A. Nienaber C.A. Pyeritz R.E. Jonker F.H. Suzuki T. et al.International Registry of Acute Aortic Dissection InvestigatorsImportance of refractory pain and hypertension in acute type B aortic dissection: insights from the International Registry of Acute Aortic Dissection (IRAD).Circulation. 2010; 122: 1283-1289Crossref PubMed Scopus (153) Google Scholar Potter et al queried the Vascular Quality Initiative (VQI) for current practice patterns regarding the timing of TEVAR in patients with type B aortic dissection and refractory hypertension and/or pain and/or rapid expansion.3Potter H.S. Ding L. Han S.M. Weaver F.A. Beck A.W. Malas M.B. et al.Impact of high-risk features and timing of repair for 1 acute type B aortic dissections.J Vasc Surg. 2022; 76: 364-371Abstract Full Text Full Text PDF Scopus (2) Google Scholar They excluded ruptures, malperfusion, and uncomplicated designation (the SVS-STS considers HRF as a subset of complicated dissection). There was no comparison to those without HRFs nor to those treated medically (VQI does not record at present). I do credit the authors for being an honest messenger to tell what happens after the SVS puts out a guiding document. I find it alarming that, of 1100 patients who met the inclusion criteria, 309 received a TEVAR within 48 hours from admission just because they had one or more HRFs. This practice led to 11% stroke rate (compared with 2.3% when TEVAR was delayed to 15 days). Their conclusion was to delay intervention for at least 2 weeks from symptom onset to improve survival and lower the rate of acute complications. However, if intervention can be delayed for 2 weeks without penalty to the patient, we all should ask, why repair earlier if at all? We are due for course correction by prospectively validating HRFs, and the VQI would be most suited for such study. The opinions or views expressed in this commentary are those of the authors and do not necessarily reflect the opinions or recommendations of the Journal of Vascular Surgery or the Society for Vascular Surgery. Impact of high-risk features and timing of repair for acute type B aortic dissectionsJournal of Vascular SurgeryVol. 76Issue 2PreviewThe new Society for Vascular Surgery/Society for Thoracic Surgery reporting standards for type B aortic dissection (TBAD) categorize clinical presentations of aortic dissection into uncomplicated, high-risk features (HRF), and complicated groups. Although it is accepted that complicated dissections require immediate repair, the optimal timing of repair for HRF has yet to be established. This study aims to identify the ideal timing of thoracic endovascular aortic repair (TEVAR) for HRF, as well as outcomes associated with specific HRF. Full-Text PDF