Is endovascular treatment preferred over aortic graft surgery for aortic dissection?

Management of Aortic Dissection: Endovascular vs. Surgical Approach

For aortic dissection, treatment should be based on the type of dissection, with endovascular treatment preferred for uncomplicated Type B dissections while open surgical repair remains the standard for Type A dissections. 1, 2

Treatment Based on Dissection Type

Type A (Ascending Aorta) Dissection

• Emergency surgical intervention is required for Type A dissections to prevent aortic rupture, pericardial tamponade, and relieve aortic regurgitation 1, 2
• Surgical options include:
  • Resection of aneurysmal aorta and proximal extent of dissection 1
  • Aortic valve resuspension for partially dissected aortic root 1
  • Aortic root replacement with composite graft for extensive dissection 1
• Endovascular stent grafts are not approved for dissections involving the ascending aorta or aortic arch 1

Type B (Descending Aorta) Dissection

• For uncomplicated Type B dissections, initial medical management with blood pressure control is recommended 3
• Endovascular stent grafting should be strongly considered for:
  • Complicated Type B dissections (malperfusion syndrome, intractable pain) 3
  • Degenerative or traumatic aneurysms exceeding 5.5 cm 1
  • Saccular aneurysms or postoperative pseudoaneurysms 1
• Benefits of endovascular approach for Type B dissections include:
  • Absence of thoracotomy incision 1
  • No need for extracorporeal circulatory support 1
  • Lower hospital morbidity rates and shorter length of stay 1

Special Considerations

Chronic Dissections

• For chronic dissection with descending thoracic aortic diameter exceeding 5.5 cm, particularly with connective tissue disorders, open repair is recommended 1
• For thoracoabdominal aneurysms exceeding 6.0 cm (or less with connective tissue disorders), elective surgery is recommended 1

Combined Approaches

• "Elephant trunk" procedures can be used to reconstruct the arch and provide a landing zone for endovascular stent grafts in the descending aorta 1
• This hybrid approach may simplify surgical procedures and shorten circulatory arrest time 4

Patient Selection Factors

• Endovascular grafting may be particularly valuable for patients with significant comorbidities (older age, cardiac, pulmonary, and renal dysfunction) who would be poor candidates for open surgery 1
• Pre-operative clinical health status is the most important determinant of post-interventional outcome for endovascular treatment 5

Outcomes and Follow-up

• Endovascular stent-graft placement for Type B dissections has shown promising results with complete thrombosis of the thoracic aortic false lumen in up to 79% of patients 6
• The open resection technique for Type A dissections has shown superior early and late results compared to the graft inclusion technique 7
• All patients require lifelong surveillance regardless of treatment approach 1
• Regular imaging follow-up is necessary to monitor for complications such as false lumen expansion or aneurysm formation 2, 3

Common Pitfalls and Caveats

• Some patients are not suitable candidates for endovascular grafting due to:
  • Absence of suitable "landing zones" above and below the aneurysm 1
  • Width of the aorta exceeding recommendations for largest available endografts 1
  • Lack of vascular access sites for deployment 1
• The rate of reoperation for Type A dissection is approximately 10% at 5 years and up to 40% at 10 years after primary surgery 2
• Endovascular treatment requires lifelong surveillance due to potential complications including endoleaks and device migration 1