Thoracic Endovascular Aortic Repair for Type B Dissection

Abstract

The development of thoracic endovascular aortic repair (TEVAR) has revolutionized the field of cardiovascular surgery. Since Parodi’s first description of an intraluminal stent graft device for the treatment of abdominal aortic aneurysms,1 endovascular device technology has rapidly evolved to treat the multiple pathologies seen in the thoracic aorta. Although TEVAR for elective repair of descending thoracic aortic aneurysm has been performed worldwide with increasing frequency,2–4 it is the role of TEVAR in acute aortic syndromes, such as aortic dissections, that has gathered increasing investigation. Article see p 407 The treatment of type B aortic dissection with TEVAR has been increasingly reported in the literature during the past decade. In patients with type B aortic dissections presenting with life-threatening complications, including rupture or malperfusion syndrome, TEVAR has become the preferred therapeutic options in most specialized aortic centers.5 Multiple studies have demonstrated dramatic improvement in perioperative outcome using TEVAR when compared with conventional open repair.6 Consequently, this has resulted in a new surgical paradigm in the treatment of complicated type B aortic dissection. In contrast, the role of TEVAR in the treatment of uncomplicated type B aortic dissection has remained a controversial debate. Since first described by Wheat7 >3 decades ago, anti-impulse therapy remains the conventional treatment paradigm of uncomplicated type B aortic dissection. Although short-term results have been acceptable, suboptimal long-term results of conventional medical therapy have frankly been disappointing, with 20% of patients developing late complications requiring intervention and 30% to 40% cumulative mortality risk at 5 years.8,9 This development of late aortic complications and compromised long-term survival have prompted investigators to find a more effective therapeutic approach and evaluate the potential role of TEVAR in this patient population. In this issue of Circulation: Cardiovascular Interventions , Nienaber et al …