Aortic Frontiers: The Prophylactic Treatment of Uncomplicated Type B Dissection

12th Biennial Meeting of the International Andreas Gruentzig Society:  Rio de Janeiro - February 2-6, 2014

From SESSION 3 — Endovascular

    Moderator:  Tyrone Collins
    Panelists:  Robert Bersin , Dieter Liermann, Klaus Mathias, Sigrid Nikol, Souheil Saddekni, Jiri Vitek, Jim Zidar

Framing the question at hand, what is the state of the current knowledge?

Acute aortic dissection is a potentially life-threatening emergency with variable presentations.  Patients often do not present with the classical symptoms of tearing or ripping pain and may go undiagnosed acutely. Complicated Type B dissections may be treated emergently with a high rate of mortality and morbidity. Uncomplicated Type B dissections are mostly treated with medical therapy in most institutions. Imaging modalities have improved the ability to characterize this disease and provide data that potentially can expand treatment options. Limited data suggest endovascular therapy as an alternative to medical and surgical treatment.

The International Registry of Acute Aortic Dissection (IRAD) was established in 1996 to assess presentation, management and outcomes of acute (less than 14 days from onset) aortic dissection.

The Investigation of STEnt Grafts in Aortic Dissection (INSTEAD) Trial was a randomized study of elective TEVAR placement in uncomplicated Type B dissection that did not demonstrate a 2-year survival benefit or decreased adverse event rates. Five year aorta-specific survival was improved with TEVAR

What are the Gaps in the current knowledge?
Although it is common medical practice, it is not known if medical therapy alone of uncomplicated Type B aortic dissection is the “gold standard” in the current practice of medicine.  What are the symptoms that warrant early treatment in afflicted patients and what complications should we look for in the long term?  There is no consensus on the timing of elective treatment and whether prophylactic therapy is justified.  In patients treated with TEVAR it is not known how much of the dissection should be treated.
For the patients treated chronically with medical therapy the recommendations for imaging follow up may be inadequate for all patients.  Whatever treatment is chosen, the economic cost of treatment and follow up must be considered.

Our Summary and Recommendations:
In select Type B dissection survivors, TEVAR should be considered along with medical therapy.  Further randomized trials and registries should evaluate the best therapy of this disease.
We recommend modifying existing guidelines to support prophylactic and early intervention in selected cases