Looking for the Holy Grail in Acute/Subacute Type B Dissection

Verhoeven, Eric L.G.; Marino, Pablo Marqués de; Katsargyris, Αthanasios

doi:10.1016/j.ejvs.2019.01.005

Cited by 3 publications

(3 citation statements)

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“…The management of TBAD is currently one of the most debated topics in Vascular Surgery with ongoing uncertainty in regards to ideal management despite international guidelines. 15 Munshi et al recently conducted a survey of Australian and New Zealand (ANZ), and European vascular surgeons, which demonstrated significant heterogeneity in management strategies both nationally and internationally. 16 Some of this uncertainty reflects the challenge of undertaking clinical trials on the management of TBAD.…”

Section: Discussionmentioning

confidence: 99%

Trends in the incidence, surgical management and outcomes of type B aortic dissections in Australia over the last decade

et al. 2023

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Objectives This study aims to investigate the incidence and in-hospital outcomes of surgical repair for type B aortic dissection (TBAD) in Australia. Methods Data were obtained from the Australasian Vascular Audit (AVA) and the Australian Institute of Health and Welfare (AIHW). The former is a total practice audit mandated for all members of the Australian and New Zealand Society for Vascular Surgery (ANZSVS) while the latter is an independent government agency which records all healthcare data in Australia. All cases of TBAD which underwent surgical intervention (endovascular or open repair) between 2010 and 2019 were identified using prospectively recorded data from the AVA (New Zealand data was excluded). The primary outcomes were temporal trends in procedures and hospital mortality; secondary outcomes were complications and risk factors for mortality. All admissions and procedures for, and hospital deaths from, TBAD in Australia were identified in AIHW datasets using the relevant diagnosis and procedure codes, with age-standardized rates calculated for the period 2000–01 to 2018–19. Results A total of 567 cases of TBAD underwent vascular surgical intervention (AVA data, Australia). Of these, 96.3% were treated by endovascular repair. There was an increase in the annual procedure number from 45 in 2010 to 88 in 2019. In-hospital mortality was 4.8% for endovascular repair and 19% for open repair ( p = 0.021). From 2000-01 to 201819, the age-standardized procedure rates for TBAD (Australia) doubled, the proportion of admitted patients undergoing a procedure rose from 28% to 43%, and in-hospital deaths fell by 25%. Conclusion There has been an increasing incidence of vascular surgical intervention for TBAD in Australia. The majority of patients received endovascular therapy while the mortality from surgically managed TBAD appears to be falling.

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Section: Discussionmentioning

confidence: 99%

Trends in the incidence, surgical management and outcomes of type B aortic dissections in Australia over the last decade

et al. 2023

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“…Verhoeven et al 5 recently reported that more vascular surgeons are adopting an aggressive approach towards early TEVAR. However, "(over)treatment of these patients by TEVAR may only mean operative risk without later benefit."…”

Section: Introductionmentioning

confidence: 99%

“…However, "(over)treatment of these patients by TEVAR may only mean operative risk without later benefit." 5 The current ambiguity of literature informing management decisions in uncomplicated TBAD means that decision making is not transparent. Hence, an increased effort should be made to understand current trends in today's clinical practice as this will assist with the design of practical and functional risk prediction tools.…”

Section: Introductionmentioning

confidence: 99%

Surgical Decision Making in Uncomplicated Type B Aortic Dissection: A Survey of Australian/New Zealand and European Surgeons

Munshi

Doyle

Ritter

et al. 2020

European Journal of Vascular and Endovascular Surgery

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WHAT THIS PAPER ADDSThe paper adds insights about current practice in uncomplicated type B aortic dissection. The data indicate influential factors, areas of uncertainty, and regional differences which may exist in decision making processes. The paper supports the design of objective risk prediction tools, and highlights considerations in establishing multicentre registries for type B aortic dissection.Objective: There is controversy about the role of pre-emptive thoracic endovascular aortic repair (TEVAR) in uncomplicated type B aortic dissection (TBAD). The aim was to understand expert opinions and the factors influencing decision making. Methods: In 2018, surgeons from Australia/New Zealand (ANZ) and Europe (EUR) were contacted to participate in an online survey which comprised questions about preferences for pre-emptive TEVAR, followed by five case scenarios, and two ranking questions for anatomical and technical risk factors respectively. Case 1 was designed to favour TEVAR in a hypertensive patient with partial false lumen thrombosis and large diameter (aortic 40 mm, false lumen 22 mm). Case 2 had no risk factors mandating TEVAR, according to current evidence. Cases 3, 4, and 5 were designed to test one risk factor respectively, large entry tear on the inner aortic curvature (10 mm), partial false lumen thrombosis, and large diameter alone. Results: There were 75 responses, 42 from EUR and 33 from ANZ. Almost half of surgeons (49.3%) endorsed preemptive TEVAR with 82.3% preferring to perform TEVAR in the subacute phase. In Case 1 and 5, 58.3% and 52.8% of surgeons respectively chose TEVAR, the highest rates obtained in the survey. Cases 1 and 5 included large diameters 40 mm, which were ranked the highest in importance when surgeons considered anatomical risk factors. Surgeons who recommend pre-emptive TEVAR were more likely to choose TEVAR in both Case 1 (83.3% vs. 33.3%, p < .001, 95% CI 27.6%e65.8%) and Case 5 (69.4% vs. 38.2%, p ¼ .008, 95% CI 8.2%e50.0%). Conclusion:In this survey about uncomplicated TBAD, about half of surgeons recommended pre-emptive TEVAR in selected cases. The surgeon's predisposition towards intervention and large diameters appear to be the most influential factors in decision making. These findings underline the uncertainty in today's practice and emphasise the need for better predictive tools.

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