Efficacy and Optimal Timing of Endovascular Treatment for Type B Aortic Dissection

Abstract

Hajime Kinoshita and Eiki Fujimoto equally contributed to this work. Objectives:To determine the efficacy and the optimal timing of thoracic endovascular aortic repair (TEVAR) for closing the primary entry in uncomplicated patients with chronic type B aortic dissection and a patent false lumen (FL). Methods: Thirteen patients underwent TEVAR for aortic dissection between 2008 and 2012. These patients had chronic dissection with a patent FL and expansion of the aorta. Early TEVAR was performed for five patients within 1-7 months from the index dissection (TEVAR-EC group) and delayed TEVAR was performed for eight patients within 1-16 years (TEVAR-DC group). Changes in the diameters and volumes of the true lumen (TL) and FL and the aortic remodeling were assessed by multidetector computed tomography for 3 years after TEVAR. Results: The reduction rate of FL in the thoracic aorta was notably higher in the TEVAR-EC group than in the TEVAR-DC group regardless of the presence or absence of distal retrograde flow. There was a significant TL expansion despite different timings of TEVAR. Conclusions: Early TEVAR resulted in good prognosis and preferable aortic remodeling in uncomplicated patients with chronic type B aortic dissection and a patent FL, and we recommend early TEVAR within seven months after the index dissection.

JCS/JSCVS/JATS/JSVS 2020 Guideline on Diagnosis and Treatment of Aortic Aneurysm and Aortic Dissection

“…Many investigators emphasize that the most appropriate timing of preemptive TEVAR is ≤6 months after onset. 1287,1295,[1368][1369][1370]1374,1375 This timing is also consistent with the period when favorable thoracoabdominal remodeling of a false lumen after TEVAR is achieved, supporting the recommendation. On the other hand, an RCT of preemptive TEVAR in the acute phase did not verify its superiority to medical treatment for the prognosis one year after TEVAR, being contrary to the above opinion.…”

“…1287, 1289 The selection of patients and timing of intervention are controversial. 385,[396][397][398][399][400]1267,[1287][1288][1289][1290][1291][1292]1295,[1368][1369][1370] Patients to be selected are those with enlargement of the false-lumen and are at risk of rupture during the chronic phase with conventional medical therapy. The condition is also termed "high-risk uncomplicated dissection".…”

Thoracic endovascular aortic repair and optimal medical treatment for acute type B penetrating aortic ulcer associated with intramural hematoma

“…[8][9][10] Early TEVAR for chronic type B dissection with a patent false lumen result in a good prognosis and favorable aortic remodeling. [11] For patients with uncomplicated type B acute aortic syndrome, antihypertensive treatment rather than surgery is acceptable for initial management. [12] However, results from the INSTEAD-XL trial encourage the use of TEVAR in patients with stable type B aortic dissection and suitable anatomy due to optimal long-term benefit.…”

Outcomes of thoracic endovascular aortic repair for chronic aortic dissections

“…TEVAR within 1 month after the index dissection has been shown to be inferior to optimal medical management, with a higher all-cause death and aorta-specific mortality. 38 TEVAR within 3 months has been shown to have more favorable aortic remodeling. 39 Fanelli et al confirmed the results of others and found a higher capacity of remodeling of acute rather than of chronic dissection after TEVAR, along with a lower false lumen thrombosis rate in chronic compared with acute dissection.…”