Guidelines
STS/AATS Guidelines for Management of Type B Aortic Dissection
In April 2022, the Society of Thoracic Surgeons (STS) and the American Association for Thoracic Surgery (AATS) published clinical guidelines on the management of type B aortic dissection (TBAD). [30] Recommendations included the following:
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In complicated hyperacute, acute, or subacute TBADs with rupture and/or malperfusion, thoracic endovascular aortic repair (TEVAR) is indicated when anatomy is favorable for such treatment.
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In patients whose anatomy is unsuitable for TEVAR, consider open surgical repair for complicated hyperacute, acute, or subacute TBADs.
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Evaluate and treat acute/subacute uncomplicated TBAD using a stepwise approach in which the location of the primary entry tear site is identified, the proximity and distance of the dissection to the left subclavian artery (LSA) is defined, the maximum orthogonal aortic diameter is calibrated, and a lack of any organ malperfusion or other indications of complicated disease is confirmed.
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For patients with uncomplicated TBAD, treatment with optimal medical therapy (OMT) is recommended.
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In patients with uncomplicated TBAD, prophylactic TEVAR may be considered to decrease late aortic-related adverse events and aortic-related death.
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Consider open surgical repair for patients with chronic TBAD who have indications for intervention, unless the patient has prohibitive comorbidities.
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In patients with chronic TBAD who have an indication for intervention and suitable anatomy (with an adequate landing zone and no ascending or arch aneurysm), TEVAR is a reasonable approach if comorbidities put the individuals at high risk for complications from open repair.
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For more durable treatment in patients with connective tissue disorders and TBAD who, despite OMT, experience disease progression, the use of open surgical repair over TEVAR is reasonable.
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Following TEVAR coverage that obstructs antegrade LSA flow, revascularization (open surgical or endovascular) of the LSA is recommended to reduce the likelihood of spinal cord ischemia (SCI).
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In type B dissection patients undergoing TEVAR, if the circumstances are nonemergent and the individuals are at increased risk for SCI (eg, if coverage is >20 cm or within 2 cm of the celiac artery origin or if other risk factors exist), establishment of cerebrospinal fluid (CSF) drainage is reasonable.
Media Gallery
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Aortic dissection. CT scan showing a flap (right side of image).
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Aortic dissection. True lumen versus false lumen in an intimal flap.
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Aortic dissection. Left subsegmental atelectasis and left pleural effusion. Flap at lower right of image.
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Aortic dissection. Significant left pleural effusion.
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Aortic dissection. CT scan showing a flap (center of image).
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Aortic dissection. CT scan showing a flap (center of image).
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Aortic dissection. CT scan showing a flap.
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Aortic dissection. CT scan showing a flap.
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Aortic dissection. Mediastinal widening.
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Aortic dissection. CT scan showing a flap.
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Aortic dissection. CT scan showing a flap.
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Aortic dissection. CT scan showing a flap.
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Aortic dissection. Thrombus and a patent lumen.
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Aortic dissection. Thrombus.
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Aortic dissection. True lumen and false lumen separated by an intimal flap.
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Aortic dissection. Mediastinal widening.
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Aortic dissection. CT scan showing a flap.
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Aortic dissection. Intimal flap and left pleural effusion.
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Image A represents a Stanford A or a DeBakey type 1 dissection. Image B represents a Stanford A or DeBakey type II dissection. Image C represents a Stanford type B or a DeBakey type III dissection. Image D is classified in a manner similar to A but contains an additional entry tear in the descending thoracic aorta. Note that a primary arch dissection does not fit neatly into either classification.
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Aortic dissection.
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Chest radiograph of a patient with aortic dissection. Image courtesy of Dr. K. London, University of California at Davis Medical Center.
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Chest radiograph of a patient with aortic dissection presenting with hemothorax.
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Chest radiograph demonstrating widened mediastinum in a patient with aortic dissection.
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Angiogram demonstrating dissection of the aorta in a patient with aortic dissection presenting with hemothorax.
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Electrocardiogram of a patient presenting to the ED with chest pain; this patient was diagnosed with aortic dissection.
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Patient with an ascending type A aortic dissection showing the intimal flap. Image courtesy of Kaiser-Permanente.
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Patient with an ascending type A aortic dissection showing the intimal flap. Image courtesy of Kaiser-Permanente.
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Patient with an ascending type A aortic dissection showing the intimal flap. Image courtesy of Kaiser-Permanente.
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Patient with an ascending type A aortic dissection showing the intimal flap. Image courtesy of Kaiser-Permanente.
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Patient with a type A aortic dissection involving the ascending and descending aorta. Image courtesy of Kaiser-Permanente.
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Patient with a type A aortic dissection involving the ascending and descending aorta. Image courtesy of Kaiser-Permanente.
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Patient with a type A aortic dissection involving the ascending and descending aorta. Image courtesy of Kaiser-Permanente.
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Patient with a type A aortic dissection involving the ascending and descending aorta. Image courtesy of Kaiser-Permanente.
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Patient showing a type B aortic dissection with extravasation of blood into the pleural cavity. Image courtesy of Kaiser-Permanente.
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Patient showing a type B aortic dissection with extravasation of blood into the pleural cavity. Image courtesy of Kaiser-Permanente.
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Patient showing a type B aortic dissection with extravasation of blood into the pleural cavity. Image courtesy of Kaiser-Permanente.
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Patient showing a type B aortic dissection with extravasation of blood into the pleural cavity. Image courtesy of Kaiser-Permanente.
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