Results of a New Surgical Paradigm: Endovascular Repair for Acute Complicated Type B Aortic Dissection

Szeto, Wilson Y.; McGarvey, Michael L.; Pochettino, Alberto; Moser, G.; Hoboken, Andrea; Cornelius, Katherine; Woo, Edward Y.; Carpenter, Jeffrey P.; Fairman, Ronald M.; Bavaria, Joseph E.

doi:10.1016/j.athoracsur.2008.04.003

Cited by 207 publications

(148 citation statements)

References 21 publications

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“…Endovascular therapy has become an option for solving malperfusion, not only for type B 74,75) but also for type A aortic dissection. 76,77) It can also be employed to malperfusion following aortic repair as well.…”

Section: Endovascular Therapymentioning

confidence: 99%

Acute Type A Aortic Dissection: for Further Improvement of Outcomes

Orihashi¹

2012

Annals of Vascular Diseases

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Despite improved outcomes of acute type A aortic dissection (AAAD), many patients die at the moment of onset, and hospital mortality is still high. This article reviews the latest literature to seek the best possible way to optimize outcomes. Delayed diagnosis is caused by variation in or absence of typical symptoms, especially in patients with neurological symptoms. Misdiagnosis as acute myocardial infarction is another problem. Improved awareness by physicians is needed. On arrival, quick admission to the OR is desirable, followed by assessment with transesophageal echocardiography, and malperfusion already exists or newly develops in the OR; thus, timely diagnosis without delay with multimodality assessment is important. Although endovascular therapy is promising, careful introduction is mandatory so as not to cause complications. While various routes are used for the systemic perfusion, not a single route is perfect, and careful monitoring is essential. Surgical treatment on octogenarians is increasingly performed and produces better outcomes than conservative therapy. Complications are not rare, and consent from the family is essential. Prevention of AAAD is another important issue because more patients die at its onset than in the following treatment. In addition to hereditary diseases, including bicuspid aortic valve disease, the management of blood pressure is important.Keywords: aortic dissection, malperfusion, complication, echocardiography A cute type A aortic dissection (AAAD) not only causes sudden death at the time of onset but leads to various life-threatening complications. In spite of improved diagnostic imaging and surgical strategies, in-hospital mortality is still high, and patients who have survived often suffer from sequelae that make subsequent quality of life poor. This article is aimed to review the latest literature and ideas to seek the best possible way to minimize undesirable results.Various complications of AAAD caused by separation of the aortic wall to outer and inner layers are summarized as three categories: 1) aortic rupture due to disruption of the outer layer; 2) malperfusion caused by the inner layer, that is, the intimal flap; and 3) aortic regurgitation by a deformed aortic valve, leading to acute heart failure. Approximately 20% of patients instantaneously die due to aortic rupture, 1) and 1 to 2% of the remaining patients die every hour unless appropriately treated. 2) Although surgical outcomes are gradually improving, in-hospital mortality of surgical patients (repair on the aortic root to the arch) in 2009 was as high as around 10%, according to the Japanese database. 3) For the further improvement of outcomes, problems should be solved in each of preonset, pre-hospital, and in-hospital stages. In this review, the latter two stages are discussed first, since most of the literature focuses on these stages. After that, the issue of pre-onset stage, i.e., prevention is discussed. DelayeD DiagnosisIn consideration of the natural history of AAAD, the "chain of onset-to-sur...

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Section: Endovascular Therapymentioning

confidence: 99%

Acute Type A Aortic Dissection: for Further Improvement of Outcomes

Orihashi¹

2012

Annals of Vascular Diseases

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“…20 Currently, there are three meta-analyses published which report the short and mid-term result in complicated TBAD patients treated with TEVAR. [106][107][108] In-hospital mortality ranged from 7.3% to 11.5% and stroke from 1.9% to 6.3%.…”

Section: Chronic Treatmentmentioning

confidence: 99%

“…Complicated TBAD is defined by the presence of at least one of the following symptoms or signs: aortic rupture, hypotension/shock, malperfusion, neurological signs, acute renal failure, recurrent or refractory pain, refractory hypertension, and/or early aortic dilatation or propagation of dissection. 8,13,20,21 Uncomplicated TBAD refers to stable patients lacking these symptoms and signs at presentation and during the hospital course. 13,18,22 The inhospital survival for complicated TBAD patients is approximately 50%, while about 90% of uncomplicated TBAD patients survive until discharge.…”

Section: Introductionmentioning

confidence: 99%

Update in the management of type B aortic dissection

et al. 2016

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Stanford type B aortic dissection (TBAD) is a life-threatening aortic disease. The initial management goal is to prevent aortic rupture, propagation of the dissection, and symptoms by reducing the heart rate and blood pressure. Uncomplicated TBAD patients require prompt medical management to prevent aortic dilatation or rupture during subsequent follow-up. Complicated TBAD patients require immediate invasive management to prevent death or injury caused by rupture or malperfusion. Recent developments in diagnosis and management have reduced mortality related to TBAD considerably. In particular, the introduction of thoracic stent-grafts has shifted the management from surgical to endovascular repair, contributing to a fourfold increase in early survival in complicated TBAD. Furthermore, endovascular repair is now considered in some uncomplicated TBAD patients in addition to optimal medical therapy. For more challenging aortic dissection patients with involvement of the aortic arch, hybrid approaches, combining open and endovascular repair, have had promising results. Regardless of the chosen management strategy, strict antihypertensive control should be administered to all TBAD patients in addition to close imaging surveillance. Future developments in stent-graft design, medical therapy, surgical and hybrid techniques, imaging, and genetic screening may improve the outcomes of TBAD patients even further. We present a comprehensive review of the recommended management strategy based on current evidence in the literature.

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“…2) Endovascular repair of acute complicated type B dissection with a stent-graft is proven to be technically feasible and effective. 3) The important point of an emergency or urgent operative strategy decision is if staged or not. It is diffi cult to repair either only through median sternotomy or left lateral thoracotomy protecting the myocardium and cerebrum.…”

Section: Discussionmentioning

confidence: 99%

A Single Stage Hybrid Repair of a Complicated Acute Type B Dissection with Aortic Arch Involvement

Higashi¹,

Matsumura²,

Yamaki³

2014

Annals of Vascular Diseases

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We present a case in which a single stage hybrid repair was successfully for a complicated acute type B dissection of the aortic arch involvement in a 63-year-old male patient. We performed a combination of different techniques; left subclavian artery debranching, elephant trunk insertion without aortic arch replacement, and thoracic endovascular aortic repair (TEVAR) from antegrade approach. The postoperative course was successful, and the patient was discharged on day 11 after surgery. A-half-year's follow up computed tomography (CT) scan showed shrinkage of thrombus lumen, vascular reverse remodeling.

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Results of a New Surgical Paradigm: Endovascular Repair for Acute Complicated Type B Aortic Dissection

Cited by 207 publications

References 21 publications

Acute Type A Aortic Dissection: for Further Improvement of Outcomes

Acute Type A Aortic Dissection: for Further Improvement of Outcomes

Update in the management of type B aortic dissection

A Single Stage Hybrid Repair of a Complicated Acute Type B Dissection with Aortic Arch Involvement

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