Commentary: Sometimes an old dogma needs a new stent

Central MessageAt one time reserved as a less morbid treatment for complicated type B dissection, TEVAR may play role in uncomplicated disease.See Article page 26. At disease. See Traditional teaching dictates Stanford aortic dissection (TBAD) is best treated with optimal medical therapy (OMT). Surgery, the dictum holds, patients at risk catastrophic sequala of their dissection. This recommendation was driven by high morbidity related to open repair thoracic aorta. Taking most ill surgery resulted in-house mortality up 30% undergoing versus around 9.0% those stenting or therapy.1Tsai T.T. Isselbacher E.M. Trimarchi S. Bossone E. Pape L. Januzzi J.L. et al.Acute dissection: does arch involvement affect management and outcomes? Insights from International Registry Acute Aortic Dissection (IRAD).Circulation. 2007; 116: I150-I156PubMed Google Scholar,2Elefteriades J.A. Lovoulos C.J. Coady M.A. Tellides G. Kopf G.S. Rizzo Management descending dissection.Ann Thorac Surg. 1999; 67 (discussion 2014-19): 2002-2005Abstract Full Text PDF PubMed Scopus (187) Scholar Patients dissections were typically medically surveyed. Surgery used if aorta showed evidence aneurysmal false lumen enlargement. Over past 2 decades, endovascular established efficacy disease, including TBAD. Thoracic (TEVAR) first demonstrated clinical utility TBAD.3Dake M.D. Kato N. Mitchell R.S. Semba C.P. Razavi M.K. Shimono T. al.Endovascular stent-graft placement acute dissection.N Engl J Med. 340: 1546-1552Crossref (1070) The INSTEAD (Investigation Stent Grafts Trial) study compared OMT (n = 68) 72) TBAD.4Nienaber C.A. Kische Rousseau H. Eggebrecht Rehders T.C. Kundt long-term results randomized investigation stent grafts trial.Circ Cardiovasc Interv. 2013; 6: 407-416Crossref (565) survival benefit not obvious until 5 years following presentation.4Nienaber In this edition Journal, Xiang colleagues5Xiang D. Kan X. Liang Xiong B. Wang al.Comparison mid-term outcomes dissection.J 2021; 162: 26-36.e1Abstract (13) provide retrospective review large cohort that further supports rationale Their corroborates earlier work, parallel between groups, which diverge after about years. remodeling thrombosis has been postulated be use TEVAR.6Schwartz S.I. Durham C. Clouse W.D. Patel V.I. Lancaster R.T. Cambria R.P. al.Predictors late intervention Vasc 2018; 67: 78-84Abstract (42) data presented colleagues challenge hypothesis, patency similar among groups. effectiveness control heart rate blood pressure well quantified. It seems likely subset these refractory hypertension. analysis database, colleagues7Trimarchi Eagle K.A. Nienaber Pyeritz R.E. Jonker F.H. Suzuki al.Importance pain hypertension insights 2010; 122: 1283-1289Crossref (138) greater difficult-to-treat hypertension, identified requiring >3 antihypertensive medications. Morphology, such diameter >4 cm, also shown predictor conversion interventional therapy.6Schwartz present study, average both groups much smaller (around 2.7-2.8 cm). must balanced increased spinal cord ischemic (SCI) events. report low complications. DeSart colleagues8DeSart K. Scali S.T. Feezor R.J. Hong M. Hess Jr., P.J. Beaver T.M. al.Fate ischemia complicating repair.J 58: 635-642.e632Abstract (62) described SCI occurring 57 (9.4%) 607 TEVAR. Of SCI, only 38% experienced neurologic recovery baseline. Moreover, markedly affected functional impairment due 25% who no improvement survived 1 year TEVAR, whereas 92% improved had. TBAD lies understanding individual patient–disease milieu. Factors morphology response medication should taken into account. Although than older procedures, without risk. A thoughtful approach will serve Comparison dissectionThe Journal Cardiovascular SurgeryVol. 162Issue 1PreviewTo assess early receiving (BMT). Full-Text Open Access