Commentary: A different animal but the same beast

Evolving Experience of Percutaneous Management of Type B Aortic Dissection

Objective The aim of this study was to achieve an international expert consensus on managing acute type B penetrating aortic ulcers (PAUs) and intramural haematomas (IMHs). Methods A modified Delphi consensus process was employed to develop recommendations for the management of acute type B PAU and IMH. Surveys were sent to international experts practicing in high volume aortic centres worldwide. Statements were voted on using a four point Likert scale in a three round Delphi process. Statements achieving grade A (full agreement 75%) or B (overall agreement 80%, full disagreement < 5%) were included as expert recommendations. Consistency of responses was measured using Cohen's κ and the intraclass correlation coefficient. Results Eighty three experts were included in the final analysis: 25 statements achieved a consensus, 18 (72%) receiving a grade B strength and 7 (28%) a grade A strength. Most statements (97%) had a high consistency classified as grade I or II. The expert panel agreed on the indication for thoracic endovascular aortic repair (TEVAR) for complicated IMH/PAU, defined by rupture or refractory pain/hypertension. Uncomplicated IMH/PAU should be managed conservatively and followed up with serial computed tomography imaging during the acute phase. High risk uncomplicated IMHs are identified by increased haematoma thickness, new onset or increased size of ulcer like projections, or transition to aortic dissection; high risk uncomplicated PAUs are defined by new associated haematoma, PAU width/depth increase, or total aortic diameter increase. Uncomplicated high risk IMH/PAUs may be considered for TEVAR. In performing TEVAR, a proximal sealing length > 20 mm in a site free from haematoma should be achieved, eventually extending in zone 2, with a 0 - 10% oversize. Patency of the left subclavian artery should be maintained. Conclusion An agreement among international experts was achieved on assessment, management, and follow up of acute type B IMHs and PAUs, addressing areas of inconsistencies or knowledge gaps in existing guidelines.

Comparative Outcomes of Acute Type B Aortic Dissection and Intramural Hematoma: Implications for Surgical and Endovascular Management.

Commentary: We still do not know what we do not know

Total Aortic Arch Replacements With a 4 Branched Frozen Elephant Trunk (FET) Graft in Acute Aortic Dissection (DeBakey type I)

Between a rock and a hard place? Not when dealing with traumatic aortic injuries!

Invited Commentary

Influence of distal entry tears in acute type B aortic dissection after thoracic endovascular aortic repair

Thoracic endovascular aortic repair in type a aortic dissection: Inching toward an endovascular solution

A single-center experience of type B aortic intramural hematoma

Distal Stent Graft–Induced New Entry After TEVAR or FET: Insights Into a New Disease From EuREC

Reply to the Editor

The challenge of associated intramural hematoma with endovascular repair for penetrating ulcers of the descending thoracic aorta

Predictors of Intervention in Acute Type B Aortic Penetrating Ulcer and Intramural Hematoma

To analyse the outcome and need for intervention [surgery or thoracic endovascular aortic repair (TEVAR)] in patients after surgery for remaining type B dissection after type A repair and primary type B aortic dissection. Within a 10-year period, 247 patients with remaining type B after type A, and 112 patients with primary type B aortic dissection were analysed. We assessed the clinical outcome as well as the need for intervention (surgery or TEVAR) within the aortic arch and the thoracoabdominal aorta as well as risk factors. The median follow-up was 23 months (interquartile range 5-52). There was a significant difference with regard to the status of the primary entry tear between patients after surgical repair of an acute type A aortic dissection and primary acute type B aortic dissection (patent vs. non-patent entry 35 vs. 83%, P < 0.001). The overall need for any kind of intervention (surgery or TEVAR) was 19%. Multivariate Cox regression analysis revealed a patent primary entry tear in patients after surgery for acute type A aortic dissection as an independent predictor for intervention (surgery or TEVAR) during follow-up [odds ratio (OR) 6.4; confidence interval (CI) 1.39-29.81, P = 0.017]. Multivariate Cox regression analysis did not reveal a patent primary entry tear in patients after acute type B aortic dissection as an independent predictor for intervention (surgery or TEVAR) during follow-up (OR 0.67; CI 0.27-1.69, P = 0.671). Finally, the thrombosis status of the false lumen was not an independent predictor for intervention (surgery or TEVAR) either in patients after surgery for acute type A aortic dissection (OR 3.46; CI 0.79-15.16, P = 0.100) or in patients after acute type B aortic dissection (OR 0.77; CI 0.31-1.93, P = 0.580). A remaining type B dissection after type A repair and a primary type B aortic dissection represent two distinct pathophysiological entities with regard to late outcome. The need for any kind of intervention in the thoracoabdominal aorta is significantly higher in primary type B aortic dissections. A remaining patent primary entry tear independently predicts the need for intervention (surgery or TEVAR) in patients after surgery for acute type A aortic dissection and, thereby, remains the main target of initial therapy. The thrombosis status of the false lumen seems to be of secondary importance.