Staged endovascular treatment for complicated type B aortic dissection

Abstract

Antihypertensive therapy; staged thoracoabdominal and branch vessel endoluminal repair (STABLE procedure), with stabilization of the dissection and rescue of renal function; CT imaging surveillance to monitor for any further complications.

Prospective multicenter clinical trial (STABLE) on the endovascular treatment of complicated type B aortic dissection using a composite device design

“…Indications for treatment in the overall patient group and by dissection symptom status are presented in Table III. In the overall patient group, the median number of indications was three per patient (range, [1][2][3][4][5]. A majority of patients (77.5%; 31 of 40) presented with impending aortic rupture (indicated by periaortic effusion or hematoma; 20%; 8 of 40) and/or branch vessel malperfusion (obstruction/compromise based on clinical and/or imaging evaluation by the investigative sites; 67.5%; 27 of 40).…”

“…5 Nienaber et al 6 subsequently described 12 instances (from a series of 100 patients), where persistent true lumen collapse was present after endograft coverage of the proximal entry tear and were treated with bare metal scaffolding stents. They concluded that scaffolding the distal thoracoabdominal aorta restored flow to malperfused branch vessels and induced positive aortic remodeling.…”

Endovascular Management of Thoracic Dissections

“…In light of this, some investigators have advocated the placement of bare stents into the distal thoracic aorta to provide structural stability without risking occlusion of intercostal arteries. 91 Finally, it is becoming clear that adoption of this relatively new treatment modality involves an inherent learning curve that affects not only physicians who perform endovascular procedures but also equipment designers and manufacturers. Eggebrecht et al, 68 in their meta-analysis of stent-graft management of type B aortic dissection, reported improved technical success rates in studies published between 2002 and 2004 compared with those published between 1999 and 2001.…”

Management of acute type B aortic dissections

“…In the uncomplicated chronic or sub-acute setting, subclavian artery revascularization should be performed when the patient has a previous LIMA bypass to a coronary, large segment coverage of the aorta will be performed, dominant vertebral artery on the left, extensive throacoabdominal repair is anticipated in future to help decrease risk of paraplegia. Management is still controversial with some data suggesting that coverage carries an increased stroke and ischemic risk while others use a selective approach to management 13,14 .…”