This is a well-written article by an experienced group with a relatively large number of patients treated for complicated acute type B aortic dissections. The International Registry of Acute Dissection published data noting an in-hospital mortality of 13% for all patients with acute type B dissection, with branch vessel involvement or malperfusion being an independent predictor of early death. An open surgical repair carries a mortality risk of at least 30%1Suzuki T. Mehta R.H. Ince H. Nagai R. Sakomura Y. Weber F. et al.Clinical profiles and outcomes of acute type B aortic dissection in the current era: lessons from the International Registry of Aortic Dissection (IRAD).Circulation. 2003; 108: II312-II317PubMed Google Scholar; consequently, endovascular repair has become a very attractive option. Feezor et al2Feezor R.J. Martin T.D. Hess Jr, P.J. Beaver T.M. Klodell C.T. Lee W.A. Early outcomes after endovascular management of acute, complicated type B aortic dissection.J Vasc Surg. 2009; 49 (discussion:6-7): 561-566Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar reported their experience with thoracic endovascular aortic repair for 33 patients with acute complicated type B dissection. The 30-day in-hospital mortality for their group was 21%, with 15% having permanent spinal cord complications, 12% having renal failure requiring dialysis, and a 12% incidence of stroke. Clearly, most published results are far better than this,3Eggebrecht H. Nienaber C.A. Neuhauser M. Baumgart D. Kische S. Schmermund A. et al.Endovascular stent-graft placement in aortic dissection: a meta-analysis.Eur Heart J. 2006; 27: 489-498Crossref PubMed Scopus (435) Google Scholar and the results of this manuscript reflect this as well. Nevertheless, I find very surprising and not in line with published results, that with the authors' technique of extensive aortic coverage to the celiac artery, lack of spinal protection, and 78% of patients being American Society of Anesthesiologists IV or V (an independent risk factor for poor outcome), that they would essentially have 0% paraplegia. Persistent false lumen patency is associated with continued aortic expansion and seen in about 50% of proximally stented patients. Computed tomography (CT) imaging does not reliably identify re-entry tears and, as such, extensive coverage may not necessarily provide better long-term results if there are distal tears. The provisional extension to induce complete attachment (PETTICOAT) concept may perform better if extensive apposition of the dissection flap is required. Finally, the authors conclude that the volumetric analysis of true and false lumens using 3D CT is effective; however, there may be a potential flaw in their imaging technique. They perform CT images that are not electrocardiographically gated or dynamic; consequently, they can only get a time-averaged volume of the true and false lumens. We have published on dynamic aspects of aortic dissections4Karmonik C. Bismuth J. Davies M.G. Lumsden A.B. Computational fluid dynamics as a tool for visualizing hemodynamic flow patterns.Methodist Debakey Cardiovasc J. 2009; 5: 26-33PubMed Google Scholar, 5Karmonik C. Bismuth J. Davies M.G. Shah D.J. Younes H.K. Lumsden A.B. A computational fluid dynamics study pre- and post-stent graft placement in an acute type B aortic dissection.Vasc Endovasc Surg. 2010 Dec 13; ([Epublication ahead of print])PubMed Google Scholar, 6Karmonik C. Bismuth J. Davies M.G. Younes H.K. Lumsden A.B. An image processing algorithm for the in-vivo quantification and visualization of septum motion in type III B − aortic dissections with cine magnetic resonance imaging.Conf Proc IEEE Eng Med Biol Soc. 2009; 2009: 4391-4394PubMed Google Scholar, 7Karmonik C. Bismuth J. Redel T. Anaya-Ayala J.E. Davies M.G. Shah D.J. et al.Impact of tear location on hemodynamics in a type B aortic dissection investigated with computational fluid dynamics.Conf Proc IEEE Eng Med Biol Soc. 2010; 1: 3138-3141Google Scholar, 8Karmonik C. Bismuth J.X. Davies M.G. Lumsden A.B. Computational hemodynamics in the human aorta: a computational fluid dynamics study of three cases with patient-specific geometries and inflow rates.Technol Health Care. 2008; 16: 343-354PubMed Google Scholar and find a variation in the true/false lumen of up to 20% to 50% throughout the cardiac cycle. Additionally, the benefit of dynamic imaging goes beyond simple appreciation of a septum, but rather fundamentally how that septum acts (mobility). We have found that a septum may by age be categorized as acute, but act more chronic with a rigid septum. This has potential implications for the therapy. Finally, I think knowing the volumetric analysis for a case control group being managed medically would potentially provide many answers, and could affect the management paradigm. Aortic remodeling, volumetric analysis, and clinical outcomes of endoluminal exclusion of acute complicated type B thoracic aortic dissectionsJournal of Vascular SurgeryVol. 54Issue 2PreviewStructural changes within the aorta after thoracic endovascular aortic repair (TEVAR) for acute complicated type B thoracic aortic dissections (ABAD) remain unknown. This study reviewed and analyzed morphologic changes, volumetric data, and clinical outcomes of patients with ABAD. Full-Text PDF Open Archive
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