Is clinical treatment the gold standard in the treatment of acute type B aortic dissections?

The type B aortic dissection treatment is showing a paradigm change with the consolidation of the endovascular treatment. Duarte et al.^[1] present a review of the most important works that demonstrate this evolution. The concept that the type B aortic dissection treatment is primarily clinical, with surgery reserved for complicated cases, are based on the first publications of IRAD^[2], in 20001. This work showed hospital mortality of 10% for clinically treated cases. The surgical treatment presented mortality rate of 31% with 18% of paraplegia. These results were not obtained by randomized controlled trials, nor considered the technical innovations of the elephant's trunk and cerebral anterograde perfusion. However, the patients initially treated medically, showed 20 to 50% of mortality^[3] in late evolution, providing the search for new treatments. The INSTEAD TRIAL^[4] was the first randomized multicenter study comparing the optimized medical treatment with endovascular treatment in uncomplicated type B aortic dissections in sub acute phase (15 to 30 days of evolution) and chronic (more than 30 days of evolution). This study showed that, after three years follow up, the endovascular treatment had lower mortality than medical treatment and greater aortic remodeling and minor complications related to the aorta. There is'nt scientific evidence, about the best treatment for cases of uncomplicated type B aortic dissection in acute phase (less than or equal to 14 days of evolution). Recently, the one year ADSORB TRIAL^[5] results were publishing. This work randomized the cases of uncomplicated type B aortic dissection in acute phase to optimal medical treatment and endovascular treatment + optimized medical treatment. Both groups showed no hospital mortality. The endovascular treatment group had higher aortic remodeling, with increased in the true lumen diameter, decrease the false lumen and aortic transverse diameter in one year follow up. This study, despite the small sample, brings new information and concepts. The hospital mortality was zero, lower than that of 10% presented by IRAD^[2], moreover, equalized the medical treatment results with the medical treatment associated with endovascular treatment, presented the latter positive bias after 1 year for aortic remodeling in the last group. Long-term results will be needed to consolidate the concept that the early closure of the false lumen is really independent factor for better performance and lower mortality and higher aortic remodeling, as affirmed INSTEAD TRIAL^[4] and Akutsu et al.^[6].

REFERENCES

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  Duarte JJ, Pontes JCDV, Benfatti RA, Ferrachini AL, Karakhanian WK, Razuk Filho A. Indication of endovascular treatment of type B aortic dissection - Literature review. Rev Bras Cir Cardiovasc 2014;29(3):396-401.
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  Hagan PG, Nienaber CA, Isselbahcher EM, Bruckman D, Karavite DJ, Russman PL, et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA. 2000;283(7):897-903.
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  Fann JI, Smith JA, Miller DC, Mitchell RS, Moore KA, Grunkemeier G, et al. Surgical management of aortic dissection during a 30-year period. Circulation. 1995;92(9 Suppl):II113-21.
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  Nienaber CA, Kische S, Rousseau H, Eggebrecht H, Rehders TC, Kundt G, et al; INSTEAD-XL trial. Endovascular repair of type B aortic dissection: long-term results of the randomized investigation of stent grafts in aortic dissection trial. Circ Cardiovasc Interv. 2013;6(4):407-16.
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  Brunkwall J, Kasprzak P, Verhoeven E, Heijmen R, Taylor P; ADSORB Trialists, et al. Endovascular repair of acute uncomplicated aortic type B dissection promotes aortic remodelling: 1 year results of the ADSORB trial. Eur J Vasc Endovasc Surg. 2014;48(3):285-91.
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  Akutsu K, Nejima J, Kiuchi K, Sasaki K, Ochi M, Tanaka K, et al. Effects of the patent false lumen on the long-term outcome of type B acute aortic dissection. Eur J Cardiothorac Surg. 2004;26(2):359-66.

Publication Dates

• Publication in this collection
  Jan-Mar 2015