Changing paradigm in endovascular treatment of descending thoracic aortic dissections

Descending thoracic dissections originating distal to the origin of the left subclavian artery carry a significant mortality if left untreated. Past thinking advocated avoiding surgical treatment of acute Stanford type B or DeBakey type III dissections, reserving therapy for chronic dissections over 14 days to a month after presentation. The current evolution of endovascular devices for the treatment of thoracic aneurysms has proven helpful in treating this pathology in a less invasive manner when compared to open surgical repair. The paradigm for treatment has evolved beyond the nature of the timing of the dissection: the current trend for treatment considers clinical findings and the development of complications. Complicated dissections include those that have developed aneurysmal dilatation >5.5 or 6 cm, organ or distal limb malperfusion, aortic rupture, uncontrolled hypertension even after adequate medical therapy, and persistent pain including rapid expansion of the affected aorta, among others (Table 1). This article reports on the current paradigm involving thoracic endovascular aortic repair (TEVAR) of Stanford type B or DeBakey type III dissections.