Commentary: Delaying the inevitable? Interventions for medically managed, uncomplicated type B aortic dissection

Central MessageThe incidence of late surgical and endovascular interventions may be substantial for medically managed, uncomplicated dissections the descending thoracic aorta.See Article page 958. The aorta. See Thoracic aortic repair (TEVAR) is recommended treatment patients presenting with acute type B dissection (ATBAD) that complicated by rupture or malperfusion, whereas optimal medical therapy (OMT) ATBAD.1Hiratzka L.F. Bakris G.L. Beckman J.A. Bersin R.M. Carr V.F. Casey Jr., D.E. et al.2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines diagnosis management disease.J Am Coll Cardiol. 2010; 55: e27-e129Crossref PubMed Scopus (1089) Google Scholar, 2Erbel R. Aboyans V. Boileau C. Bossone E. Bartolomeo R.D. Eggebrecht H. al.2014 ESC on diseases.Eur Heart J. 2014; 35: 2873-2926Crossref (2921) 3Estrera A.L. Miller III, C.C. Safi H.J. Goodrick J.S. Keyhani A. Porat E.E. al.Outcomes dissection.Circulation. 2006; 114: I384-I389PubMed 4Brunkwall Kasprzak P. Verhoeven Heijmen Taylor ADSORB Trialists al.Endovascular promotes remodelling: 1 year results trial.Eur J Vasc Endovasc Surg. 48: 285-291Abstract Full Text PDF (252) 5Nienaber C.A. Rousseau Kische S. Fattori Rehders T.C. al.Randomized comparison strategies dissection: INvestigation STEnt grafts in (INSTEAD) trial.Circulation. 2009; 120: 2519-2528Crossref (598) Scholar However, some data suggest ATBAD (ie, without malperfusion) deserve early intervention.6Nienaber Kundt G. long-term randomized investigation stent trial.Circ Cardiovasc Interv. 2013; 6: 407-416Crossref (723) 7Lou X. Chen E.P. Duwayri Y.M. Veeraswamy R.K. Jordan W.D. Zehner al.The impact survival dissection.Ann Thorac 2018; 105: 31-38Abstract (42) 8Iannuzzi J.C. Stapleton S.M. Bababekov Y.J. Chang D. Lancaster R.T. Conrad M.F. al.Favorable dissection.J 68: 1649-1655Abstract (40) 9Qin Y.L. Wang F. Li T.X. Ding W. Deng Xie B. compared 2016; 67: 2835-2842Crossref (82) 10Fattori Tsai T.T. Myrmel T. Evangelista Cooper J.V. Trimarchi al.Complicated surgery still best option? A report from International Registry Acute Aortic Dissection.JACC 2008; 1: 395-402Crossref (342) 11Schoder M. Czerny Cejna Rand Stadler Sodeck G.H. follow-up true false lumen diameter changes.Ann 2007; 83: 1059-1066Abstract (135) 12Sachs Pomposelli Hagberg Hamdan Wyers Giles K. al.Open Nationwide inpatient sample.J 52 (discussion 866): 860-866Abstract (108) Much uncertainty derives a dearth robust natural history describes high-risk features aneurysmal degeneration, rupture, sudden death. There are also minimal describing incidence, outcomes, risk factors intervention after OMT ATBAD.13Lou Forcillo al.Predictors failure 2019; 107: 493-498Abstract (10) Scholar,14Schwartz S.I. Durham Clouse Patel V.I. Cambria R.P. treated 78-84Abstract (70) Furthermore, few prospective trials observational studies directly compare TEVAR tend to underpowered, they analyze heterogenous patient populations (eg, vs subacute) while targeting diverse outcomes remodeling mortality) over differing time frames late).6Nienaber Given difficulties comparing these handful studies, initial (TEVAR OMT) remains controversial. In this issue Journal, Kreibich colleagues15Kreibich Siepe Berger Beyersdorf Soschynski Schlett C.L. al.Intervention rates medically-managed dissections.J 2023; 165: 958-965.e4Abstract (4) present cohort aorta (DTA), which an important addition literature. Crucially, study's population includes DTA arch involvement. Nevertheless, all were initially managed discharged their index admission presentation dissection. At 3 years, was 27% ± 10% 36% 11%, respectively. Among 30 requiring intervention, two-thirds had rapid growth (≥5 mm within year), remainder persistent symptoms rupture. (±left carotid subclavian bypass) performed 25 (83%), remaining 5 (17%) underwent open because comorbid connective tissue disease. Moreover, account competing event death, authors employed regression analysis determine intervention. For entire patients, found only predictor discharge having maximum ≥45 diagnostic computed tomography angiography. group there no observed in-hospital mortality, one permanently disabling neurologic event. should congratulated reporting valuable concerning DTA, as well superb With certain critical qualifications, evidence INSTEAD (Investigation Stent Grafts Dissection) (Acute Dissection Stentgraft Best Medical Treatment) indicated does not improve short-term ATBAD, OMT.4Brunkwall Scholar,5Nienaber 5-year INSTEAD-XL suggests confer benefit reducing aorta-related improving disease progression, augmenting positive remodeling.6Nienaber Other similar benefits.7Lou Scholar,16Sultan I. Siki M.A. Bavaria J.E. Dibble T.R. Savino D.C. Kilic al.Predicting distal chronic DeBakey III 1691-1696Abstract (31) 17Sultan Dufendach Bianco Trivedi Althouse A.D. al.Bare metal use offer aorta.Ann 106: 1364-1370Abstract 18Kilic Sultan I.S. Arnaoutakis G.J. Higgins R.S. Assessment endografting operative mortality score: development validation 2,000 patients.Ann 2015; 100: 860-867Abstract 19Brown Gleason T.G. Aranda-Michel intramural hematoma.J Card 2020; 2324-2330Crossref (12) By implication, safely delay progression,3Estrera it prevent nor promote remodeling. considering rate reported study (36% 11%) previous (40%-45%),13Lou often nevertheless To sure, interventional potentially avoids risks morbidity associated itself. allow expansion dissected aorta, leading Thus, when adverse events, situation far clear. This begs question: Are who mitigate death progression fatal despite inherent itself? colleagues, required supports concept likely safe DTA. While encouraging result, other so optimistic. estimated high 9%, significant DTA.3Estrera Scholar,20Elefteriades Lovoulos C.J. Coady Tellides Kopf G.S. Rizzo Management 1999; 2002-2019Abstract (197) 21Tsai Isselbacher al.Long-term insights Dissection.Circulation. 2226-2231Crossref (430) 22Reutersberg Trenner Haller Geisbüsch Reeps Eckstein H.H. delayed complications underestimated.J 356-363Abstract (24) study, helpfully isolated cause-specific sample size small (n = 91), 3-year incomplete unidentified number thereby limiting our ability adequately assess overall As trial demonstrates, degeneration requires at least years follow-up. subacute include radiologic clinical mortality.22Reutersberg Indeed, 7 91 total late-onset dynamic obstruction Interestingly, median 4 months (interquartile range 2, 11), means before routine 6-month visit. do comment, surveillance paradigm deserves further investigation. Finally, emphasized direct survival, assessed studies.6Nienaber excellent descriptive normative implications regimen potential indication “prophylactic” Some ATBADs such, new analytic category has recently emerged—the so-called “high-risk” category—for determining beneficiaries among ATBADs.23Lombardi Hughes G.C. Appoo J.J. Beck A.W. al.Society Vascular Surgery (SVS) Society Surgeons (STS) standards 71: 723-747Abstract (208) 24Trimarchi Tolenaar J.L. Froehlich Pegorer Upchurch G.R. al.Influence outcome evidences IRAD.J Surg (Torino). 2012; 53: 161-168PubMed 25Jonker F.H. Rampoldi O'Gara Peterson M.D. al.International (IRAD) InvestigatorsAortic 94: 1223-1229Abstract (81) 2020 guidelines argue encompass tears originating arch, but have retrograde (but ascending involvement).23Lombardi define including uncontrolled pain, refractory hypertension, bloody pleural effusion, >40 mm, radiographic arterial signs malperfusion syndrome, entry involving lesser curve >22 even 30-day hospital readmission.23Lombardi Since necessarily cohere unclear if TEVAR, opposed OMT. many characteristics been adds knowledge features. Patients thrombosis, longer extent dissection, more re-entry tears, closer proximity intimal tear left artery. multivariable analysis, variable predicting exceeding 45 mm. confirms most literature, although identified 40 cutoff.24Trimarchi isolating subgroup involvement, younger age predictive, distance artery first length demonstrate trends towards Young disease, comment relationship. again, limited robustly effects various predictors, such Another feature described reports non-A non-B (aortic dissections).26Czerny Schmidli Adler van den Berg Bertoglio L. Carrel al.Current options recommendations pathologies arch: expert consensus document European Association Cardio-Thoracic (EACTS) (ESVS).Eur Cardiothorac 133-162Crossref (236) 27Rylski Pérez Reser Kari F.A. al.Acute outcome.Eur 2017; 52: 1111-1117Crossref (43) 28Nauta F.J. Desai N.D. al.Impact extension outcomes.Ann 102: 2036-2043Abstract (41) 29Loewe Ta Schoder Funovics al.A mechanism primarily complicated, becomes uncomplicated.Ann 93: 1215-1222Abstract (71) 30Weiss Wolner Folkmann Grabenwöer location primary affects 42: 571-576Crossref (93) Previous conflicting,26Czerny involvement being risk,29Loewe Scholar,30Weiss others not.28Nauta upfront replacements frozen elephant trunks. groups prompt caution interpreting results. unable alone, presumably due limitations, unique amongst subtypes ATBAD. Despite observations, clear conclusion, considerations need 11%), encouraging, since study. angiography final however, assesses arguably clinically meaningful measures. currently designed, unclear. fact cohort—treated under conservative needed—is certainly reassuring. Intervention dissectionsThe Journal Cardiovascular SurgeryVol. 165Issue 3PreviewTo evaluate dissections. Full-Text