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Classification system can help determine treatment for aortic dissection

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HOLLYWOOD, Fla. — A mnemonic-based classification system using six clinical and anatomic features can help clinicians determine whether patients with aortic dissection need open surgery, endovascular treatment or medical management, an expert said here.

Michael D. Dake

The most widely used algorithms are more than 45 years old and were devised before endovascular treatment was an option, Michael D. Dake, MD, the Thelma and Henry Doegler professor in the department of cardiothoracic surgery at Stanford University School of Medicine and Falk Cardiovascular Research Center, said during a presentation at the International Symposium on Endovascular Therapy.

In addition, he said, the 2014 European Society of Cardiology guidelines on aortic dissection state that patients with Type A aortic dissection should have urgent open surgery, those with complicated Type B aortic dissection should have thoracic endovascular aortic repair (TEVAR), and those with uncomplicated type B aortic decision should have optimal medical therapy but also getting TEVAR may be considered, creating uncertainty as to which patients in that class should get TEVAR.

Therefore, he said, the DISSECT classification system was created to “address six specific anatomic and clinical manifestations of the dissection process that are most relevant to decision-making” and to “facilitate optimal communication among medical providers of the most salient details to inform a critical analysis of the therapeutic options.”

He said the six aspects of the system are:

Duration. Currently this is classified as acute, subacute and chronic, but Dake said in the future it may be classified by number of days or months between diagnosis and presentation.

Intimal entry tear location. “This is obviously key if you’re going to consider stent graft coverage of the entry tear,” he said. “Going forward, we will fold in the actual size of the entry tear, which up until now really hasn’t been a consideration.”

Size of aorta (maximum diameter). This will tell whether there is a preexisting aneurysm and the literature suggests that those with aortic diameter > 40 mm “are at highest risk for early progression of disease and development of aortic events,” he said.

Segimental Extent of dissection.

Clinical condition. In addition to whether it is complicated or uncomplicated, this also includes whether there is a rupture, whether branch vessels are symptomatic and whether there is early aortic dilatation, all of which “are complicated situations which will lead you towards early intervention,” Dake said.

Thrombosis of aortic false lumen. That is, whether it is patent, partially thrombosed or completely thrombosed. One study found that partial thrombosis was associated with the worst outcomes, he said.

“When you’re finished with this, you’ve probably got all the relevant information you need to triage a patient,” Dake said. – by Erik Swain

Reference:

Dake MD. Session VI: Update on Aortic Dissection Management. Presented at: International Symposium on Endovascular Therapy; Feb. 6-10, 2016; Hollywood, Fla.

Disclosure: Dake reports financial ties with Cardinal Health, Cook Medical, C.R. Bard, Intact Vascular, Novate, PQ Bypass and W.L. Gore.