Advertisement

Acute Type B Aortic Dissection

  • Ashraf A. Sabe
  • G. Chad HughesEmail author
Chapter
  • 10 Downloads

Abstract

Acute type B aortic dissection (identified within 2 weeks of symptom onset), as described using the Stanford classification, involves the aorta distal to the left subclavian artery and accounts for 25–40% of all aortic dissections. The traditional treatment paradigm of medical management for uncomplicated acute type B dissection and open surgical intervention for early or late complications of type B dissection is currently undergoing a period of evolution as a result of the influence of minimally invasive thoracic endovascular aortic repair options. Thoracic endovascular repair has replaced open surgical repair as the preferred treatment for complicated acute type B dissection, and may also prove beneficial for prophylactic repair of uncomplicated acute type B dissection for high-risk patients. This chapter discusses the management of acute type B aortic dissection and long-term treatment considerations.

Keywords

Acute type B aortic dissection Aortic dissection Aortic emergency Stanford classification system Thoracic endovascular aortic repair 

References

  1. 1.
    Juang D. Aortic dissections. www.iradonline.org. Accessed 12 Jan 2019.
  2. 2.
    Riambau V, Böckler D, Brunkwall J, et al. Editor’s choice – management of descending thoracic aorta diseases: clinical practice guidelines of the european society for vascular surgery (ESVS). Eur J Vasc Endovasc Surg. 2017;53:4–52.PubMedCrossRefPubMedCentralGoogle Scholar
  3. 3.
    Hughes GC. Management of acute type B aortic dissection; ADSORB trial. J Thorac Cardiovasc Surg. 2015;149(2 Suppl):S158–62.PubMedCrossRefPubMedCentralGoogle Scholar
  4. 4.
    Trimarchi S, Eagle KA, Nienaber CA, et al. Importance of refractory pain and hypertension in acute type B aortic dissection: insights from the International Registry of Acute Aortic Dissection (IRAD). Circulation. 2010;122:1283–9.PubMedCrossRefPubMedCentralGoogle Scholar
  5. 5.
    Trimarchi S, Tolenaar JL, Tsai TT, Froehlich J, Pegorer M, Upchurch GR, Fattori R, Sundt TM 3rd, Isselbacher EM, Nienaber CA, Rampoldi V, Eagle KA. Influence of clinical presentation on the outcome of acute B aortic dissection: evidences from IRAD. J Cardiovasc Surg. 2012;53:161–8.Google Scholar
  6. 6.
    Hughes GC, Andersen ND, McCann RL. Management of acute type B aortic dissection. J Thorac Cardiovasc Surg. 2013;145(3 Suppl):S202–7.PubMedCrossRefPubMedCentralGoogle Scholar
  7. 7.
    Patel AY, Eagle KA, Vaishnava P. Acute type B aortic dissection: insights from the International Registry of Acute Aortic Dissection. Ann Cardiothorac Surg. 2014;3:368–74.PubMedPubMedCentralGoogle Scholar
  8. 8.
    Cohn LH, Adams DH. Cardiac surgery in the adult 5/e. New York, NY: McGraw Hill Professional; 2017.Google Scholar
  9. 9.
    Isselbacher EM, Bonaca MP, Di Eusanio M, et al. Recurrent aortic dissection: observations from the International Registry of Aortic Dissection. Circulation. 2016;134:1013–24.PubMedCrossRefGoogle Scholar
  10. 10.
    Atkins MD, Black JH, Cambria RP. Aortic dissection: perspectives in the era of stent-graft repair. J Vasc Surg. 2006;43:A30–43.CrossRefGoogle Scholar
  11. 11.
    Suzuki T, Mehta RH, Ince H, et al. Clinical profiles and outcomes of acute type B aortic dissection in the current era: lessons from the International Registry of Aortic Dissection (IRAD). Circulation. 2003;108(Suppl 1):II312–7.PubMedPubMedCentralGoogle Scholar
  12. 12.
    Tsai TT, Fattori R, Trimarchi S, et al. Long-term survival in patients presenting with type B acute aortic dissection: insights from the International Registry of Acute Aortic Dissection. Circulation. 2006;114:2226–31.PubMedCrossRefPubMedCentralGoogle Scholar
  13. 13.
    Nienaber CA, Rousseau H, Eggebrecht H, et al. Randomized comparison of strategies for type B aortic dissection: the INvestigation of STEnt Grafts in Aortic Dissection (INSTEAD) trial. Circulation. 2009;120:2519–28.PubMedPubMedCentralCrossRefGoogle Scholar
  14. 14.
    Nienaber CA, Kische S, Rousseau H, et al. Endovascular repair of type B aortic dissection: long-term results of the randomized investigation of stent grafts in aortic dissection trial. Circ Cardiovasc Interv. 2013;6:407–16.PubMedPubMedCentralCrossRefGoogle Scholar
  15. 15.
    Brunkwall J, Kasprzak P, Verhoeven E, et al. Endovascular repair of acute uncomplicated aortic type B dissection promotes aortic remodelling: 1 year results of the ADSORB trial. Eur J Vasc Endovasc Surg. 2014;48:285–91.PubMedCrossRefPubMedCentralGoogle Scholar
  16. 16.
    Famularo M, Meyermann K, Lombardi JV. Aneurysmal degeneration of type B aortic dissections after thoracic endovascular aortic repair: a systematic review. J Vasc Surg. 2017;66:924–30.PubMedCrossRefPubMedCentralGoogle Scholar
  17. 17.
    Evangelista A, Salas A, Ribera A, et al. Long-term outcome of aortic dissection with patent false lumen: predictive role of entry tear size and location. Circulation. 2012;125:3133–41.PubMedCrossRefPubMedCentralGoogle Scholar
  18. 18.
    Coady MA, Ikonomidis JS, Cheung AT, et al. American Heart Association Council on Cardiovascular Surgery and Anesthesia and Council on Peripheral Vascular Disease. Surgical management of descending thoracic aortic disease: open and endovascular approaches. Circulation. 2010;121:2780–804.PubMedCrossRefGoogle Scholar
  19. 19.
    Ray HM, Durham CA, Ocazionez D, et al. Predictors of intervention and mortality in patients with uncomplicated acute type B aortic dissection. J Vasc Surg. 2016;64:1560–8.PubMedCrossRefPubMedCentralGoogle Scholar
  20. 20.
    Svensson LG, Kouchoukos NT, Miller DC, et al. Expert consensus document on the treatment of descending thoracic aortic disease using endovascular stent-grafts. Ann Thorac Surg. 2008;85(Suppl 1):S1–41.PubMedPubMedCentralCrossRefGoogle Scholar
  21. 21.
    Hanna JM, Andersen ND, Ganapathi AM, McCann RL, Hughes GC. Five-year results for endovascular repair of acute complicated type B aortic dissection. J Vasc Surg. 2014;59:96–106.PubMedCrossRefGoogle Scholar
  22. 22.
    Andersen ND, Keenan JE, Ganapathi AM, Gaca JG, McCann RL, Hughes GC. Current management and outcome of chronic type B aortic dissection: results with open and endovascular repair since the advent of thoracic endografting. Ann Cardiothorac Surg. 2014;3:264–74.PubMedPubMedCentralGoogle Scholar
  23. 23.
    Hiratzka LF, Bakris GL, Beckman JA, et al., American College of Cardiology Foundation; American Heart Association Task Force on Practice Guidelines; American Association for Thoracic Surgery; American College of Radiology; American Stroke Association; Society of Cardiovascular Anesthesiologists; Society for Cardiovascular Angiography and Interventions; Society of Interventional Radiology; Society of Thoracic Surgeons; Society for Vascular Medicine. ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation. 2010;121:e266–369.PubMedGoogle Scholar
  24. 24.
    Fattori R, Cao P, De Rango P, et al. Interdisciplinary expert consensus document on management of type B aortic dissection. J Am Coll Cardiol. 2013;61:1661–78.PubMedPubMedCentralCrossRefGoogle Scholar
  25. 25.
    Hughes GC. Stent graft-induced new entry tear (SINE): intentional and NOT. J Thorac Cardiovasc Surg. 157(1):101–2019, 106.e3.PubMedCrossRefGoogle Scholar
  26. 26.
    Mukohara N. Intramural hematoma – contradiction to the theory of rupture of the vasa vasorum at onset. Ann Thorac Cardiovasc Surg. 2014;20:949–50.PubMedCrossRefGoogle Scholar
  27. 27.
    Lansman SL, Saunders PC, Malekan R, Spielvogel D. Acute aortic syndrome. J Thorac Cardiovasc Surg. 2010;140(6 Suppl):S92–7.PubMedCrossRefGoogle Scholar
  28. 28.
    Baikoussis NG, Apostolakis EE, Siminelakis SN, Papadopoulos GS, Goudevenos J. Intramural haematoma of the thoracic aorta: who’s to be alerted the cardiologist or the cardiac surgeon? J Cardiothorac Surg. 2009;4:54.PubMedPubMedCentralCrossRefGoogle Scholar
  29. 29.
    Trimarchi S, Tsai T, Eagle KA, et al. Acute abdominal aortic dissection: insight from the International Registry of Acute Aortic Dissection (IRAD). J Vasc Surg. 2007;46:913–9.PubMedCrossRefGoogle Scholar
  30. 30.
    Harris KM, Braverman AC, Eagle KA, et al. Acute aortic intramural hematoma: an analysis from the International Registry of Acute Aortic Dissection. Circulation. 2012;126(11 Suppl 1):S91–6.PubMedPubMedCentralCrossRefGoogle Scholar
  31. 31.
    Tolenaar JL, Harris KM, Upchurch GR Jr, et al. The differences and similarities between intramural hematoma of the descending aorta and acute type B dissection. J Vasc Surg. 2013;58:1498–504.PubMedCrossRefPubMedCentralGoogle Scholar
  32. 32.
    Kret MR, Azarbal AF, Mitchell EL, Liem TK, Landry GJ, Moneta GL. Compliance with long-term surveillance recommendations following endovascular aneurysm repair or type B aortic dissection. J Vasc Surg. 2013;58:25–32.PubMedCrossRefPubMedCentralGoogle Scholar
  33. 33.
    Andersen ND, Hanna JM, Ganapathi AM, et al. Insurance status predicts acuity of thoracic aortic operations. J Thorac Cardiovasc Surg. 2014;148:2082–6.PubMedPubMedCentralCrossRefGoogle Scholar
  34. 34.
    Andersen ND, Brennan JM, Zhao Y, et al. Insurance status is associated with acuity of presentation and outcomes for thoracic aortic operations. Circ Cardiovasc Qual Outcomes. 2014;7:398–406.PubMedPubMedCentralCrossRefGoogle Scholar
  35. 35.
    Andersen ND, Hanna JM, Bhattacharya SD, et al. Insurance status predicts non-elective case status but not outcomes of thoracic aortic operations. J Am Coll Surg. 2012;215:S45–6.CrossRefGoogle Scholar
  36. 36.
    Fazel R, Gerber TC, Balter S, et al. Approaches to enhancing radiation safety in cardiovascular imaging: a scientific statement from the American Heart Association. Circulation. 2014;130:1730–48.PubMedCrossRefPubMedCentralGoogle Scholar
  37. 37.
    van Bakel TMJ, et al. Cardiac remodelling following thoracic endovascular aortic repair for descending aortic aneurysms. Eur J Cardiothorac Surg. 2018;55(6):1061–70.CrossRefGoogle Scholar
  38. 38.
    Hiraoka A, Toki M, Hayashida A, et al. Exercise stress echocardiogram for the evaluation of change in the ventricular-arterial interaction after thoracic endovascular aortic repair. Eur J Cardiothorac Surg. 2019;55:632–8.  https://doi.org/10.1093/ejcts/ezy342.CrossRefPubMedPubMedCentralGoogle Scholar
  39. 39.
    Andersen ND, Ganapathi AM, Hanna JM, Williams JB, Gaca JG, Hughes GC. Outcomes of acute type a dissection repair before and after implementation of a multidisciplinary thoracic aortic surgery program. J Am Coll Cardiol. 2014;63:1796–803.PubMedPubMedCentralCrossRefGoogle Scholar
  40. 40.
    Andersen ND, Benrashid E, Ross AK, et al. The utility of the aortic dissection team: outcomes and insights after a decade of experience. Ann Cardiothorac Surg. 2016;5:194–201.PubMedPubMedCentralCrossRefGoogle Scholar
  41. 41.
    Williams DM, Lee DY, Hamilton BH, et al. The dissected aorta: percutaneous treatment of ischemic complications—principles and results. J Vasc Interv Radiol. 1997;8:605–25.PubMedCrossRefGoogle Scholar
  42. 42.
    Yang B, Patel HJ, Williams DM, Dasika NL, Deeb GM. Management of type A dissection with malperfusion. Ann Cardiothorac Surg. 2016;5:265–74.PubMedPubMedCentralCrossRefGoogle Scholar
  43. 43.
    Elefteriades JA. Thoracic aortic aneurysm: reading the enemy’s playbook. Curr Probl Cardiol. 2008;33:203–77.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.Division of Thoracic and Cardiovascular SurgeryDuke University Medical CenterDurhamUSA
  2. 2.Duke Center for Aortic DiseaseDuke Center for Structural Heart DiseaseDurhamUSA

Personalised recommendations