Contemporary Management of Acute Type B Dissection

Publication date: Available online 9 December 2015
Source:European Journal of Vascular and Endovascular Surgery
Author(s): A.J. Scott, C.D. Bicknell
ObjectiveGrowing confidence in thoracic endovascular aortic repair (TEVAR) for the management of acute type B aortic dissection has resulted in controversies regarding optimum patient selection and the timing of intervention. In this review a clinical vignette to present a practical perspective on the contemporary management of acute type B dissection (ABAD) in a specialist vascular centre with particular focus on areas of debate is used.MethodsThis is a narrative clinical review.ResultsAggressive anti-impulse therapy is the cornerstone of management of all patients with ABAD. However, 20–30% of patients develop complicated ABAD defined by the presence of malperfusion syndromes, acute aortic dilatation, dissection extension, or persistent pain and hypotension. These complicated patients typically require intervention, and non-randomised series suggest TEVAR to be an effective alternative to open repair with a lower morbidity. There is considerable interest and controversy surrounding the use of TEVAR in uncomplicated ABAD patients for whom the intervention-free survival at 6 years is less than 50% for patients managed with anti-impulse therapy. Data regarding this question are sparse, but two randomised trials (ADSORB and INSTEAD) both demonstrated a higher rate of favourable aortic remodelling in patients managed with TEVAR than medical therapy alone. However, it is unclear whether this positive remodelling translates into a reduction in long-term mortality sufficient to balance the early perioperative hazards of endografting.ConclusionDespite increasing adeptness at endovascular stenting, the long-term outcomes of patients with ABAD leave significant room for improvement. In particular, the optimum management of patients with uncomplicated disease is unclear and guidance from trials powered for long-term mortality is awaited. Until then, the principals of management of ABAD remain aggressive medical therapy for all patients, with TEVAR primarily reserved for those who develop complications.



from Endocrinology via ola Kala on Inoreader http://ift.tt/1OU4wsB
via IFTTT

from #Med Blogs by Alexandros G.Sfakianakis via Alexandros G.Sfakianakis on Inoreader http://ift.tt/1Q1F9Zg
via IFTTT