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Contemporary Management of Acute Type B Aortic Dissections
Hiranya A. Rajasinghe MDThe Vascular Group of Naples, PLCNaples, Florida
DISSECTION TYPES
Type A Type B
PATHOGENESIS
TYPE A Ao DISSECTION
TYPE B Ao DISSECTION
ACUTE TYPE B AORTIC DISSECTION
25-40 % of all dissections
• 80 % (uncomplicated), preferred management is medical Rx
• 15 -20% (complicated): rupture, malperfusion, refractory medical therapy/HTN – consider surgical or endovascular Rx
International Registry of Aortic Dissection (IRAD)
International Registry of Aortic Dissection (IRAD)
International Registry of Aortic Dissection (IRAD)
Uncomplicated TBAD: Does it Exist?
Endovascular Repair of Type B Aortic Dissection
by Christoph A. Nienaber, Stephan Kische, Hervé Rousseau, Holger Eggebrecht, Tim C. Rehders, Guenther Kundt, Aenne Glass, Dierk Scheinert, Martin Czerny, Tilo Kleinfeldt, Burkhart Zipfel, Louis Labrousse, Rossella Fattori, and Hüseyin Ince
Circ Cardiovasc IntervVolume 6(4):407-416
August 20, 2013
Copyright © American Heart Association, Inc. All rights reserved.
Illustration demonstrating typical features of type B dissection with flow in both the true and the expanded false lumen resulting from a major proximal entry tear (left).
Christoph A. Nienaber et al. Circ Cardiovasc Interv. 2013;6:407-416
A, Kaplan–Meier estimates of all-cause mortality (death) and Landmark analysis with a breakpoint at 24 months after randomization to the end of the trial are shown for optimal
medical treatment (OMT) and OMT + thoracic endovascular aortic repair (TEVAR) groups.
Gadolinium-enhanced sagittal MR angiogram of type B dissection before randomization (top) and 5 years after endovascular repair (bottom).
Christoph A. Nienaber et al. Circ Cardiovasc Interv. 2013;6:407-416
TEVAR FOR AORTIC DISSECTIONPREVENTS LATE EXPANSION; ENCOURAGES AORTIC
REMODELING
All-Cause Mortality p=0.13
Aorta-Specific Mortality p=0.04
Disease Progression p=0.040%
10%
20%
30%
40%
50% OMT n=68
TEVAR+OMT n=72
Cumulative Clinical Results: Year 0 through Year 5
19.3% 19.3%
46.1%
11.1%
27.0%
19.1%Absolute Risk
Reduction
12.4%Absolute Risk
Reduction
6.9%
High-Risk Uncomplicated Acute TBAD Uncertainty remains regarding optimal management strategy
for high-risk uncomplicated acute TBAD
Consideration of early intervention appears reasonable in following scenarios:• Initial aortic diameter ≥ 4.0cm with patent false lumen• ≥ 22mm false lumen in proximal DTA• Recurrent/refractory pain or HTN• Partially thrombosed false lumen• Proximal entry tear ≥ 10mm• Entry tear on inner curve
Well-designed, prospective, randomized trial needed