Type B Aortic Dissections: When to Intervene

During Tuesday’s Aortic Updates session, Dr. Joseph Lombardi from Cooper University Hospital in Camden, New Jersey, presented an overview of intervention for type B aortic dissections (TBAD). The dilemma, he said, is when intervention is necessary vs when intervention is prudent. Speaking of complicated TBAD, he noted that thoracic endovascular aortic repair (TEVAR) is the gold standard for patients who present with rupture and malperfusion. But what about uncomplicated TBAD?

Uncomplicated TBAD is divided into 3 categories: acute (1-14 days), subacute (15-90 days), and chronic (over 90 days). In acute TBAD, no benefit has been demonstrated with early TEVAR. The key marker in chronic TBAD is aortic growth; if there is no growth, continued observation is needed. An article by Lombardi et al published in 2020 in the Journal of Vascular Surgery and the Journal of Thoracic Surgery presented a new reporting category: high risk. This includes refractory pain and hypertension, bloody pleural effusions, aortic diameter >40 mm, false lumen diameter > 22mm, radiographic-only malperfusion, readmission for dissection-related events, and entry tear: lesser curve location.

In conclusion, Dr. Lombardi stated that truly uncomplicated TBAD is best managed with best medical therapy, and TEVAR is now the gold standard for complicated TBAD. The new high risk category demonstrates early growth, persistent pain, and poor blood pressure control as target scenarios for early treatment. Planning TEVAR in the subacute phase will likely decrease operative morbidity.