Commentary: The 2-step strategy

Central MessageStratification of uncomplicated type B aortic dissection and correct timing for TEVAR improves survival and prevents aortic-related adverse events.See Article page 4. Stratification of uncomplicated type B aortic dissection and correct timing for TEVAR improves survival and prevents aortic-related adverse events. See Article page 4. According to current guidelines, complicated type B aortic dissection (TBAD) requires endovascular therapy.1Erbel R. Aboyans V. Boileau C. Bossone E. Di Bartolomeo R. Eggebrecht H. et al.2014 ESC guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The task force for the diagnosis and treatment of aortic diseases of the European Society of Cardiology (ESC).Eur Heart J. 2014; 35: 2873-2926Crossref PubMed Scopus (3030) Google Scholar Nonetheless, the treatment of uncomplicated TBAD (uTBAD) remains controversial.1Erbel R. Aboyans V. Boileau C. Bossone E. Di Bartolomeo R. Eggebrecht H. et al.2014 ESC guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The task force for the diagnosis and treatment of aortic diseases of the European Society of Cardiology (ESC).Eur Heart J. 2014; 35: 2873-2926Crossref PubMed Scopus (3030) Google Scholar In this setting, thoracic endovascular aortic repair (TEVAR) has gained consensus over time; however, its recommendation remains in class IIa due to the lack of clinical trials.1Erbel R. Aboyans V. Boileau C. Bossone E. Di Bartolomeo R. Eggebrecht H. et al.2014 ESC guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The task force for the diagnosis and treatment of aortic diseases of the European Society of Cardiology (ESC).Eur Heart J. 2014; 35: 2873-2926Crossref PubMed Scopus (3030) Google Scholar Spinelli and colleagues2Spinelli D. Weaver F.A. Azizzadeh A. Magee G.A. Piffaretti G. Benedetto F. et al.Endovascular treatment of complicated versus uncomplicated acute type B aortic dissection.J Thorac Cardiovasc Surg. 2023; 165: 4-13.e1Abstract Full Text Full Text PDF Scopus (8) Google Scholar add evidence on the safety, efficacy, and usefulness of TEVAR in uTBAD. Analyzing Gore's Global Registry for Endovascular Aortic Treatment Registry, the authors report comparable outcomes between patients with complicated TBAD and uTBAD in terms of mortality, aortic complications, and reinterventions. The rationale of applying TEVAR in the treatment of TBAD is to seal the intimal tear, allowing the true lumen expansion and reducing the tension of the false lumen (FL) to promote its thrombosis. Moreover, endovascular aortic repair should reduce the risk of aortic remodeling and aortic-related complications (eg, aneurysm formation, rupture, and organ ischemia).3Schepens M.A.A.M. Type B aortic dissection: new perspectives.J Vis Surg. 2018; 4: 75Crossref PubMed Google Scholar Nevertheless, this procedure may be complicated by retrograde aortic dissection and the rate of reinterventions for endoleaks is around 24%.4Hughes G.C. Management of acute type B aortic dissection: ADSORB trial.J Thorac Cardiovasc Surg. 2015; 149: S158-S162Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar The treatment of uTBAD with TEVAR should be carefully evaluated according to patient-specific presentation, weighting benefits and risks of the procedure. Reviewing preoperative computed tomographic images of uTBAD patients, Sailer and colleagues5Sailer A.M. van Kuijk S.M. Nelemans P.J. Chin A.S. Kino A. Huininga M. et al.Computed tomography imaging features in acute uncomplicated Stanford type-B aortic dissection predict late adverse events.Circ Cardiovasc Imaging. 2017; 10: e005709Crossref PubMed Scopus (62) Google Scholar identified 5 risk factors: connective disorders, circumferential extension of FL, the maximal aortic diameter, FL outflow, and intercostal branches involved. Based on these characteristics, they were able to stratify patients in low, intermediate, or high risk for adverse events. Moreover, the concavity of the distal arch and entry tears >10 mm were associated with poor prognosis at either presentation or during hospitalization.6Weiss G. Wolner I. Folkmann S. Sodeck G. Schmidli J. Grabenwöger M. et al.The location of the primary entry tear in acute type B aortic dissection affects early outcome.Eur J Cardiothorac Surg. 2012; 42: 571-576Crossref PubMed Scopus (95) Google Scholar,7Loewe C. Czerny M. Sodeck G. Ta J. Schoder M. Funovics M. et al.A new mechanism by which an acute type B aortic dissection is primarily complicated, becomes uncomplicated, or remains uncomplicated.Ann Thorac Surg. 2012; 93: 1215-1222Abstract Full Text Full Text PDF PubMed Scopus (74) Google Scholar Finally, Sato and colleagues8Sato H. Ito T. Kuroda Y. Uchiyama H. Watanabe T. Yasuda N. et al.New predictor of aortic enlargement in uncomplicated type B aortic dissection based on elliptic Fourier analysis.Eur J Cardiothorac Surg. 2017; 52: 1118-1124Crossref PubMed Scopus (8) Google Scholar reported that the shape of the true lumen was a predictor for aortic growth. Using these tools, a tailored approach can be hypothesized. In the study presented by Spinelli and colleagues,2Spinelli D. Weaver F.A. Azizzadeh A. Magee G.A. Piffaretti G. Benedetto F. et al.Endovascular treatment of complicated versus uncomplicated acute type B aortic dissection.J Thorac Cardiovasc Surg. 2023; 165: 4-13.e1Abstract Full Text Full Text PDF Scopus (8) Google Scholar it would have been of interest to stratify the risk of aortic adverse events of uTBAD patients receiving TEVAR. It is well known that optimal anti-impulse therapy (OMT) is effective in controlling symptoms and is associated with an intrahospital survival of 90%.3Schepens M.A.A.M. Type B aortic dissection: new perspectives.J Vis Surg. 2018; 4: 75Crossref PubMed Google Scholar However, survival decreases to 64% and 29% in intermediate and high-risk patients, respectively.9Tsai T.T. Fattori R. Trimarchi S. Isselbacher E. Myrmel T. Evangelista A. 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: 2226-2231Crossref PubMed Scopus (437) Google Scholar We recommend early TEVAR treatment in high-risk patients, whereas low-risk patients may follow a delayed 2-step strategy consisting of OMT first and TEVAR second.10Alfson D.B. Ham S.W. Type B aortic dissections: current guidelines for treatment.Cardiol Clin. 2017; 35: 387-410Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar OMT induces partial FL thrombosis, reduces aortic wall tension, and allows tissues thickening as result of inflammation. All of these factors are less likely to have aortic procedure-related complications.11Yuan X. Clough R.E. Nienaber C.A. Management of uncomplicated type B aortic dissection.Hearts. 2020; 1: 14-24Crossref Google Scholar,12Thakkar D. Dake M.D. Management of type B aortic dissections: treatment of acute dissections and acute complications from chronic dissections.Tech Vasc Interv Radiol. 2018; 21: 124-130Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar However, chronicization reduces the tissue elasticity, lowering the possibility of effectively reducing the FL.11Yuan X. Clough R.E. Nienaber C.A. Management of uncomplicated type B aortic dissection.Hearts. 2020; 1: 14-24Crossref Google Scholar,12Thakkar D. Dake M.D. Management of type B aortic dissections: treatment of acute dissections and acute complications from chronic dissections.Tech Vasc Interv Radiol. 2018; 21: 124-130Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar In light of these considerations, stratification and timing are essential to maximize TEVAR benefit and reduce postoperative complications. Despite this, the Interventional Stent Treatment Acute Dissection trial and Acute Dissection: Stent Graft or Best Medical Therapy trial failed to show lower mortality with TEVAR over OMT, and TEVAR was associated with higher rate of FL thrombosis and reduced aortic remodeling at follow-up.13Nienaber C.A. Kische S. Rousseau H. Eggebrecht H. Rehders T.C. Kundt G. 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: 407-416Crossref PubMed Scopus (741) Google Scholar,14Brunkwall J. Kasprzak P. Verhoeven E. Heijmen R. Taylor P. Canaud L. 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: 285-291Abstract Full Text Full Text PDF PubMed Scopus (260) Google Scholar Because a number of patients with uTBAD will develop postdissection aneurysms requiring surgery, we can conclude that OMT alone remains a suboptimal treatment and elective TEVAR may play an important role in preventing aortic wall remodeling. Endovascular treatment of complicated versus uncomplicated acute type B aortic dissectionThe Journal of Thoracic and Cardiovascular SurgeryVol. 165Issue 1PreviewThe study objective was to analyze the outcomes of thoracic endovascular aortic repair performed for complicated and uncomplicated acute type B aortic dissections. Full-Text PDF