Commentary: The evolving management of type B aortic dissection

Central MessageOptimal management of type B aortic dissections requires an understanding of the anatomy, chronicity, and patient-specific factors, summarized in a clinical guideline that will change over time.See Article page 1231. Optimal management of type B aortic dissections requires an understanding of the anatomy, chronicity, and patient-specific factors, summarized in a clinical guideline that will change over time. See Article page 1231. As our understanding of aortic disease progresses, so does the need to provide a set of up-to-date, evidence-driven, consensus guidelines. Such guidelines are not meant to be static but rather a living document that can (and will) change as newer data are added. Previous guidelines have been published at moderate intervals with the compendium and summary of pertinent data inclusive of all aortic disease.1Hiratzaka L.F. Bakris G.L. Beckman J.A. Bersim R.M. Carr V.F. Casey Jr., D.E. et al.2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine.Circulation. 2010; 121: e266-e369Google Scholar Recently, the American Association for Thoracic Surgery provided a more focused guideline for the management of acute type A aortic dissection (TAAD),2Malaisrie S.C. Szeto W.Y. Halas M. Girardi L.N. Coselli J.S. Sundt III, T.M. et al.2021 The American Association for Thoracic Surgery expert consensus document: surgical treatment of acute type A aortic dissection.J Thorac Cardiovasc Surg. 2021; 162: 735-758.e2Google Scholar this has been followed by the American Association for Thoracic Surgery/Society of Thoracic Surgeons guideline for the management of type B aortic dissection (TBAD) in this issue of the Journal of Thoracic and Cardiovascular Surgery.3MacGillivray T.E. Gleason T.G. Patel H.J. Aldea G.S. Bavaria J.E. Beaver T.M. et al.The Society of Thoracic Surgeons/American Association for Thoracic Surgery clinical practice guidelines on the management of type B aortic dissection.J Thorac Cardiovasc Surg. 2022; 163: 1231-1249Google Scholar TBADs vis-à-vis TAADs at present have a wider range of therapeutic approaches and surgical options. This is not because of more clinical trials that have compared outcomes but more likely reflects the evolution of innovative methods for dealing with a complicated problem. Several factors account for this inexactitude in TBAD therapy. One is that the early mortality of untreated TAAD is prohibitive, whereas in TBAD it is not. Second is the lack of clarity around the long-term benefits of medical therapy in patients with TBAD and the ability to ameliorate future complications such as aneurysmal degeneration. Third is the lack of widely available endovascular solutions for TAAD. To date there has not been a large, prospective clinical trial that has compared open surgical with endovascular approaches with TBAD, and likely there never will. The 2 more well known and frequently referenced trials, Acute Dissection: Stent graft OR Best medical therapy (ADSORB)4Kamman A.V. Brunkwall J. Verhoeven E.L. Heijmen R.H. Trimarchi S. ADSORB trialistsPredictors of aortic growth in uncomplicated type B aortic dissection from the Acute Dissection Stent Grafting or Best Medical Treatment (ADSORB) database.J Vasc Surg. 2017; 65: 964-971Google Scholar and Investigation of Stent Grafts in Patients with Type B Aortic Dissection (INSTEAD),5Nienaber C.A. Kische S. Akin I. Rousseau H. Eggebrecht H. Fattori R. et al.Strategies for subacute/chronic type B aortic dissection: the Investigation of Stent Grafts in Patients with Type B Aortic Dissection (INSTEAD) trial 1-year outcome.J Thorac Cardiovasc Surg. 2010; 140: S101-S108Google Scholar both compared thoracic endovascular aortic repair (TEVAR) with optimal medical management and both were small studies—ADSORB had 61 patients (31 optimal medical therapy and 30 TEVAR) and INSTEAD had 140 patients (68 optimal medical therapy and 72 TEVAR). Despite the small group sizes important clinical information was obtained (eg, the importance of eliminating or minimizing flow in the false lumen). MacGillivray and colleagues3MacGillivray T.E. Gleason T.G. Patel H.J. Aldea G.S. Bavaria J.E. Beaver T.M. et al.The Society of Thoracic Surgeons/American Association for Thoracic Surgery clinical practice guidelines on the management of type B aortic dissection.J Thorac Cardiovasc Surg. 2022; 163: 1231-1249Google Scholar have taken the best current and available data to provide us with a series of recommendations for the management of TBAD. As is the custom, the process is divided by 2 major variables, chronicity (acute vs chronic) and effect (complicated vs noncomplicated). Without oversimplifying too much, Figure 1 shows a rubric for the general management of TBAD. There are many caveats to this rubric—it does not consider anatomic features that might complicate TEVAR, approaches might be limited by the experience of the providers, and it does not include patients with connective tissue disorders, etc. Nonetheless, what is apparent and what is acknowledged by the authors is the empty space in the lower right corner and one area that is ripe for future studies and examination. Specifically, what do we need to do for the chronic, noncomplicated TBAD? How often should TBAD be imaged as part of a surveillance strategy? As evidence and experience grow, these recommendations will be refined, with the work of MacGillivary and colleagues laying the foundation. The Society of Thoracic Surgeons/American Association for Thoracic Surgery clinical practice guidelines on the management of type B aortic dissectionThe Journal of Thoracic and Cardiovascular SurgeryVol. 163Issue 4PreviewAs a result of the rapidly evolving technology and techniques to manage patients with type B aortic dissection (TBAD), The Society of Thoracic Surgeons (STS) and the American Association for Thoracic Surgery (AATS) convened a panel of expert aortic surgeons to methodically review the current data to provide recommendations on the management of patients with TBAD. Full-Text PDF