From the Guidelines
Vascular intervention is indicated for type B aortic dissection in cases of complicated acute dissection, including aortic rupture, branch artery occlusion and malperfusion, extension of the dissection flap, aortic enlargement, intractable pain, and uncontrolled hypertension, as recommended by the 2024 ESC guidelines 1. The primary goal of intervention is to prevent life-threatening complications and relieve symptoms.
- Indications for vascular intervention include: + Aortic rupture + Branch artery occlusion and malperfusion + Extension of the dissection flap + Aortic enlargement + Intractable pain + Uncontrolled hypertension Endovascular repair, typically involving thoracic endovascular aortic repair (TEVAR), is the preferred approach when intervention is necessary, as it aims to cover the primary entry tear, redirect blood flow into the true lumen, and promote false lumen thrombosis 1. For patients not meeting these criteria, medical management with blood pressure control and close monitoring is recommended, with beta-blockers as the first-line agents, and regular imaging follow-up to monitor for disease progression 1. The specific indications balance the risks of intervention against the natural history of the disease, prioritizing the prevention of aortic rupture and end-organ malperfusion, which can lead to significant morbidity and mortality if left untreated, as outlined in the 2022 ACC/AHA guideline for the diagnosis and management of aortic disease 2.
From the Research
Indications for Vascular Intervention
The indications for vascular intervention in Type B aortic dissection are as follows:
- Complicated type B dissections, including: + Impending rupture 3, 4, 5, 6 + Malperfusion syndromes 3, 4, 5, 6 + Rupture 4, 5, 6 + Uncontrolled pain or blood pressure 3 + Aneurysmal expansion 3
- Uncomplicated type B dissections, in select patients with suitable anatomy, to mitigate the risks of mid and late-term disease progression and aortic-related mortality 4, 5, 6
Treatment Options
Treatment options for Type B aortic dissection include:
- Medical management for uncomplicated cases, centered on the use of antihypertensive agents 7
- Thoracic endovascular aortic repair (TEVAR) for complicated cases, which has emerged as an alternative to open surgical repair 3, 4, 5, 6
- Intentional rupture of the dissection membrane to obliterate the false lumen, and the candy-plug technique to eliminate retrograde flow in the false lumen, for select patients 6