Type B Aortic Dissections: Current Guidelines for Treatment

doi:10.1016/j.ccl.2017.03.007

Cardiology Clinics

Volume 35, Issue 3, August 2017, Pages 387-410

https://doi.org/10.1016/j.ccl.2017.03.007 Get rights and content

Section snippets

Key points

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Stanford type B aortic dissections (TBADs) involve the descending aorta and are further classified by time of onset and presence of complications.
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Diagnosis begins with clinical suspicion and is confirmed with imaging of the entire aorta.
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Anti-impulse medical therapy is the cornerstone of treatment and should be initiated immediately on diagnosis for all aortic dissections.
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Thoracic endovascular aortic repair (TEVAR) is indicated in patients with complicated TBAD as well as during the subacute

Epidemiology and risk factors

The yearly incidence of aortic dissections as a group historically has been reported as 3 to 4 per 100,000 persons22, 23; however, a more recent review of more than 30,000 patients in Sweden reported a much higher yearly incidence of 15 per 100,000 persons.²⁴ TBAD accounts for approximately 25% to 40% of all aortic dissections,25, 26 with a yearly incidence of approximately 2 per 100,000 persons.²⁷ An IRAD review of 4428 patients with aortic dissections over a 17-year period demonstrated 33%

Clinical History and Physical Examination

The diagnosis of TBAD is primarily clinical with confirmation based on imaging studies.³⁰ The most common presenting complaint is severe or worst-ever pain typically described as sharp (68%) rather than tearing or ripping (52%).¹⁰ Most (89%) patients describe this pain as occurring abruptly, located most often in the back (64%–70%), chest (63%–67%), or abdomen (43%), with few patients (20%–25%) describing migratory pain.10, 20, 28, 29, 31 Patients may also present with other signs or symptoms

Historical Perspectives

Aortic dissections were originally described by Morgagni in 1761. Meaningful treatment of this rapidly lethal condition was initially limited because antemortem diagnosis was infrequent. Moreover, until the invention of cardiopulmonary bypass in the mid-1950s, surgical management was essentially impossible.¹⁰ The first report of successful open surgical repair of aortic dissections was published in 1955 by DeBakey and colleagues,³⁵ awakening hope, albeit short-lived, for an effective treatment

Follow-up and surveillance

Outpatient monitoring of patients with TBAD after acute management, either with medical or surgical therapy, is mandatory. Continuation of anti-impulse therapy with control of blood pressure and heart rate is essential to prevent disease progression, even after TEVAR. Imaging with serial CTA of the entire aorta is the cornerstone of surveillance. General recommendations include having the first follow-up CTA completed 1 month after acute presentation whether managed medically or with TEVAR to

Future directions

Expertise in aortic dissections, specifically TBADs, is a misnomer because there remains much to be learned about this complex vascular pathology in terms of early diagnosis, risk-prediction, and optimal therapeutic strategies. An array of several biomarkers, such as smooth muscle myosin heavy chain, soluble elastin fragments, polycistin 1, and D dimer, are being analyzed as potential indicators for early diagnosis of acute aortic dissections.¹¹¹ Based on in vitro models of hemodynamic flow