Type B aortic dissection: new perspectives

Abstract

Background: Stanford type B aortic dissection is one of the aortic catastrophes with a high mortality and morbidity that needs immediate or delayed treatment, either surgically or endovascularly. This comprehensive review article addresses the current status of open, endovascular and hybrid treatment options for type B aortic dissections with the focus on new therapeutic perspectives.

Methods: Evaluation of currently available evidence based on randomized and registry data and personal experience.

Results: All type B dissections require prompt medical treatment to prevent aortic rupture. Acute complicated dissections are nowadays treated by endografting to reroute blood flow into the true lumen and promote false lumen thrombosis and future aortic remodeling. In acute uncomplicated situations the position of endografting is less clear and should be further delineated; however, on the long run also in these situations endografting might be protective for future aortic catastrophes in certain patient categories. In the chronic dissection with aneurysm formation of the descending thoracic and/or thoracoabdominal aorta, especially in connective tissue disorders, open surgery offers nowadays the best immediate results with long durability. Thoracic endografting plays only a minor role in these circumstances but branched and fenestrated endografting are very promising techniques. Hybrid techniques can offer the solution for high risk patients that are not suitable for open surgery.

Conclusions: Emergent thoracic endografting is the golden standard for all complicated type B dissections while uncomplicated patients with high-risk features might benefit from endovascular repair. Open surgery is limited for chronic post dissection aneurysms. Aortic surveillance is of paramount importance in all situations.

Keywords: Stanford type B aortic dissection; aorta; open surgery; thoracic endovascular aortic repair (TEVAR); thoracoabdominal aneurysm.

Figure 1

An example of a chronic post dissection aneurysm in the descending aorta.

Figure 2

The dissected thoracoabdominal aorta was treated by TEVAR limited to the thoracic aorta, retrograde filling of the false lumen is visible.

Figure 3

Retrograde filling of the false lumen in the thoracic aorta from within the abdominal aorta via a re-entry tear.