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Candidates for medical management identified in type B aortic dissection

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Michael D. Dake

HOLLYWOOD, Fla. — While thoracic endovascular aortic repair has been shown to benefit many patients with uncomplicated type B aortic dissection, certain patients may do better with medical treatment.

At the International Symposium on Endovascular Therapy (ISET), Michael D. Dake, MD, the Thelma and Henry Doelger Professor at Stanford Hospital and Clinics, Stanford University, said patients with multiple risk factors for a poor TEVAR outcome should be managed medically.

“We have to think about who we shouldn’t treat with TEVAR because they’re at high risk for complications from our procedure,” he said. “Patients that have many of these risk factors together should still be treated medically. The management decision is predicated on that fact that they may be at high risk for complications.”

Dake identified the following pathology and anatomy considerations that may make a patient too high-risk to undergo TEVAR for uncomplicated type B aortic dissection:

• Chronic type B dissection.

• Connective tissue disease.

• A false lumen that is completely thrombosed throughout the full extent of the process.

• A dissection hematoma or other acute involvement extending into zone 2.

• A highly angulated arch such as one with gothic, peaked or cathedral characteristics, with an apex “neck” seal zone.

• Primary intimal tear within the visceral segment.

• Unsuitable and un-reconstructable access to the aorta.

• Multi-barrel channels (> 2).

• Sustained need for chronic anticoagulation.

These factors “may make patients at risk for retrograde type A dissection from TEVAR or some other complication,” Dake said. “The field is moving to increase our prognostic scope beyond how to assess the individual risk to a patient with uncomplicated type B dissection toward how best to predict the risk of disease progression after TEVAR.” – by Erik Swain

Reference:

Dake MD. Session 4: Aortic dissection and complex TEVAR and TAVR. Presented at: the International Symposium on Endovascular Therapy (ISET); Feb. 3-7, 2018; Hollywood, Fla.

Disclosure: Dake reports he is a consultant for Cook Medical, C.R. Bard and Novate Medical and receives grant/research support from Cook Medical, Essential Medical, Novate Medical and W.L. Gore and Associates.