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Treatment algorithms for patients with (sub)acute type B aortic dissections
Kyriakos Oikonomou1, Athanasios Katsargyris, George Kouvelos
1Department of Vascular and Endovascular Surgery, Paracelsus Medical University, Nuremberg, Germany - eric.verhoeven@klinikum-nuernberg.de.
Insights
Acute type B aortic dissection management is shifting. Endovascular repair (TEVAR) is preferred for complicated cases, while early TEVAR may prevent late complications in selected uncomplicated cases.
Area of Science:
- Cardiovascular Medicine
- Vascular Surgery
- Interventional Cardiology
Background:
- Aortic dissection, particularly type B, is a critical cardiovascular emergency.
- Traditional management stratified treatment based on complicated (surgical) vs. uncomplicated (medical) dissection.
- A paradigm shift towards endovascular repair for complicated type B aortic dissection is evident.
Purpose of the Study:
- To review current literature on treatment options for acute type B aortic dissection.
- To discuss the optimal timing for intervention.
- To propose a treatment algorithm for acute type B aortic dissection.
Main Methods:
- Review of existing literature and meta-analyses comparing endovascular repair (TEVAR) with open surgical repair.
- Analysis of outcomes for medical management versus early TEVAR in uncomplicated cases.
- Synthesis of evidence to inform treatment recommendations.
Main Results:
- TEVAR demonstrates lower perioperative mortality and morbidity compared to open surgery for complicated type B dissection.
- Best medical therapy has acceptable early outcomes but may not prevent late aortic complications.
- Early TEVAR shows potential for false lumen thrombosis and aortic remodeling in selected patients.
Conclusions:
- TEVAR is increasingly the standard for complicated acute type B aortic dissection.
- Early TEVAR should be considered preventively in select uncomplicated cases with suitable anatomy.
- A proposed treatment algorithm aims to optimize management strategies for acute type B aortic dissection.
Abstract:
Aortic dissection is the most common acute aortic syndrome and constitutes a potentially catastrophic cardiovascular condition. Traditionally, complicated acute type B dissection has been considered an indication for surgical treatment, whereas patients with uncomplicated dissection have been treated medically. In recent years, there has been a clear paradigm shift towards endovascular treatment of complicated type B dissection. This is founded in numerous reviews and meta-analyses demonstrating a lower perioperative mortality and morbidity for TEVAR in comparison to open surgical repair. In uncomplicated patients, treatment options are still a matter of debate. Best medical therapy shows acceptable early results with respect to in-hospital mortality and morbidity but fails to address the issue of late aortic expansion and aortic-related adverse events in a significant number of patients. There is increasing evidence that early TEVAR promotes false lumen thrombosis, induces remodeling of the aortic wall and should be considered preventively in selected patients with suitable anatomy. This report gives an overview of current literature on treatment options and optimal time of intervention, and finally proposes a treatment algorithm for acute type B aortic dissection.
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