From the Guidelines
Surgery for type B aortic dissection is indicated in patients with complications such as rupture or impending rupture, malperfusion syndrome, persistent or recurrent pain, uncontrollable hypertension, and rapid aortic expansion, as stated in the 2024 ESC guidelines for the management of peripheral arterial and aortic diseases 1.
Indications for Surgery
The following are specific scenarios where surgery is necessary:
- Rupture or impending rupture of the aorta
- Malperfusion syndrome affecting vital organs, such as the kidneys, intestines, or lower extremities
- Persistent or recurrent pain despite medical management
- Uncontrollable hypertension
- Rapid aortic expansion, with a diameter exceeding 5.5 cm or an increase of greater than 10 mm per year
Recommended Treatment Approach
The recommended surgical approach is endovascular repair (TEVAR) as the first-line treatment, which involves placing a stent graft to cover the primary entry tear and redirect blood flow through the true lumen, as recommended by the 2024 ESC guidelines 1.
Benefits of Intervention
The goal of intervention is to prevent life-threatening complications by restoring proper blood flow to vital organs and stabilizing the aortic wall to prevent rupture, thereby reducing mortality rates and improving quality of life, as supported by the 2022 ACC/AHA guideline for the diagnosis and management of aortic disease 1.
Key Considerations
It is essential to consider the patient's overall risk profile, including the presence of connective tissue disorders, such as Marfan syndrome, which may increase the risk of complications, as noted in the 2024 ESC guidelines 1.
From the Research
Indications for Surgery in Type B Aortic Dissection
The indications for surgery in a Type B aortic dissection include:
- Malperfusion 2, 3, 4
- Rapid expansion 2, 3, 4
- Retrograde dissection 2
- Rupture 2, 3, 4
- Intractable pain 3, 4
- Uncontrolled hypertension 4
- Threatened exsanguination 4
Surgical Management
Surgical management is generally reserved for patients with complicated Type B aortic dissections, such as those with signs of malperfusion, rapid expansion, or rupture 3, 4, 5, 6. However, some studies suggest that prophylactic endovascular therapy may be beneficial for patients with uncomplicated Type B aortic dissections who are at high risk for long-term aortic complications 2, 5, 6.
Endovascular Intervention
Endovascular intervention, such as thoracic endovascular aortic repair (TEVAR), is being increasingly used to treat Type B aortic dissections, particularly in patients with complicated dissections 3, 5, 6. The use of endovascular intervention in uncomplicated Type B aortic dissections is still a topic of debate, but some studies suggest that it may be beneficial in certain patient populations 2, 5, 6.