What are the sequelae of a standard type B dissection (type B aortic dissection)?

From the Guidelines

Standard B dissection sequela management should prioritize aggressive blood pressure control with beta-blockers as first-line agents, combined with regular imaging surveillance and lifestyle modifications to prevent complications and improve patient outcomes. The management of standard B dissection sequela involves a comprehensive approach to prevent complications and improve patient outcomes. According to the 2024 ESC guidelines for the management of peripheral arterial and aortic diseases 1, antihypertensive therapy is recommended in all patients with chronic type B aortic dissection.

Key Components of Management

• Aggressive blood pressure control with medications such as beta-blockers (metoprolol 25-100mg twice daily or labetalol 100-300mg twice daily) as first-line agents, often combined with ACE inhibitors or calcium channel blockers to maintain systolic blood pressure below 120-130 mmHg 1
• Regular imaging surveillance with CT angiography recommended at 1,3,6, and 12 months after the initial event, then annually thereafter to monitor for signs of aneurysmal expansion (>5.5cm diameter or growth >0.5cm/year) 1
• Lifestyle modifications including smoking cessation, moderate exercise avoiding Valsalva maneuvers, and sodium restriction to reduce the risk of complications 1
• Long-term pain management may be necessary, typically starting with non-opioid analgesics 1

Importance of Surveillance

The 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease emphasize the importance of periodic surveillance imaging to monitor the affected aorta for further dilatation 1. This is crucial in identifying patients who may require surgical intervention to prevent complications such as rupture or malperfusion syndromes.

Recent Guidelines

The 2024 ESC guidelines for the management of peripheral arterial and aortic diseases provide the most recent and highest quality evidence for the management of standard B dissection sequela 1. These guidelines recommend a multidisciplinary approach to management, including medical therapy, imaging surveillance, and lifestyle modifications to improve patient outcomes. By prioritizing aggressive blood pressure control, regular imaging surveillance, and lifestyle modifications, clinicians can reduce the risk of complications and improve quality of life for patients with standard B dissection sequela.

From the Research

Standard B Dissection Sequela

• The sequela of standard B dissection can be severe and often lethal, with complications such as rupture, malperfusion, aneurysmal degeneration, and intractable pain 2.
• The management of Type B aortic dissection (TBAD) remains controversial, with many groups recommending conservative therapy for newly diagnosed TBAD and reserving surgical management for patients who develop complications 2.
• Beta-blockers are known to protect a vulnerable aorta from acute dissection, as well as reducing the risk of recurrent dissection 3.
• The use of oral beta-blockers has been associated with significant protection against in-hospital mortality and stroke following repair of TBAD 4.
• Intravenous metoprolol has been shown to reduce mortality in patients with TBAD, with a dose of ≤10 mg associated with significant mortality reduction 4.

Medical Therapy

• The mainstay of medical therapy for TBAD includes antihypertensive medication to reduce ΔP/ ΔT by lowering blood pressure and heart rate 2.
• Beta-blockers are first-line anti-impulse therapy for patients presenting with acute type B aortic dissection (TBAD) 5.
• Postoperative beta-blocker use has been associated with improved early aortic remodeling, with increased complete false lumen thrombosis observed in patients taking beta-blockers 5.

Surgical Management

• Thoracic endovascular aortic repair (TEVAR) has been extended to treat TBAD in selected patients, with promising outcomes and early mortality rates from 10% to 20% 2.
• The goals of endovascular treatment of TBAD are to cover the entry tear, treat or prevent impending rupture, reestablish organ perfusion, restore flow in the true lumen, and induce the false lumen thrombosis 2.
• TEVAR has been shown to be effective in promoting complete false lumen thrombosis, with beta-blocker use associated with increased complete false lumen thrombosis 5.