Last updated March 14, 2022

Management of Type B Aortic Dissection

Acute Complicated TBAD

TEVAR is indicated for complicated hyperacute, acute, or subacute TBADs with rupture and/or malperfusion and favorable anatomy for TEVAR. (I, B-NR)
573

Open surgical repair for complicated hyperacute, acute, or subacute TBADs should be considered for those patients with unsuitable anatomy for TEVAR. (IIa, B-NR)
573

Fenestration may be considered for complicated hyperacute, acute, or subacute TBADs. (IIb, C-LD)
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Uncomplicated TBAD

A stepwise approach to the evaluation and treatment of acute/subacute uncomplicated TBAD should be applied that includes identification of the primary entry tear site location, defining the proximity and distance of the dissection to the LSA, calibration of the maximum orthogonal aortic diameter, and confirmation of the lack of any organ malperfusion or other indications of complicated disease. (I, B-NR)
573

OMT is the recommended treatment for patients with uncomplicated TBAD. (I, B-NR)
573

Prophylactic TEVAR may be considered in patients with uncomplicated TBAD to reduce late aortic-related adverse events and aortic-related death. (IIb, B-NR)
573

Close clinical follow-up after hospital discharge is recommended for patients presenting with acute TBAD. (I, B-NR)
573

Chronic TBAD

Open surgical repair should be considered for patients with chronic TBAD with indications for intervention, unless comorbidities are prohibitive or anatomy is not suitable for TEVAR. (IIa, B-NR)
573

TEVAR is reasonable for patients with chronic TBAD with an indication for intervention with suitable anatomy (adequate landing zone, absence of ascending or arch aneurysm) but who are at high risk for complications of open repair due to comorbidities. (IIa, B-NR)
573

TEVAR alone as sole therapy is not recommended in patients with chronic TBAD who have a large abdominal aortic aneurysm, an inadequate distal landing zone, and/or large distal reentry tears. (III - No Benefit, C-LD)
573

Timing of Intervention

In patients with acute uncomplicated TBAD with high-risk features, it may be reasonable to consider delaying treatment (beyond 24 hours up to 90 days) with TEVAR to reduce early adverse events and to improve late outcomes. (IIb, C-LD)
573

Connective Tissue Disorders

Open surgical repair over TEVAR is reasonable for more durable treatment in patients with connective tissue disorders and TBAD who have progression of disease despite OMT. (I, B-NR)
573

EVAR is reasonable in patients with connective tissue disorders with acute complicated TBADs and anatomy favorable for TEVAR as a bridge to delayed open reconstruction. (IIa, C-LD)
573

Spinal Cord Protection Adjuncts to TEVAR

Revascularization (open surgical or endovascular) of the LSA after TEVAR coverage that obstructs antegrade LSA flow is recommended to decrease the risk of SCI. (I, B-NR)
573

It is reasonable to establish CSF drainage in type B dissection patients undergoing TEVAR if they are at increased risk for SCI (eg, coverage >20 cm or within 2 cm of the celiac artery origin or other risk factors) and time permits (ie, nonemergent circumstances). (IIa, B-NR)
573

It is reasonable to establish CSF drainage in type B dissection patients who develop symptoms of paraparesis/paraplegia. (IIa, B-NR)
573

Management of TBAD With Arch Involvement

Optimal medical therapy is reasonable in patients with uncomplicated TBAD and retrograde extension of dissection from a tear at or distal to the LSA, as long as retrograde extension is limited to the arch (zones 1 and 2). (IIa, C-LD)
573

Table 1 - Morphologic features posing high risk of late sequelae

  • Primary entry tear at greater curve of distal arch
  • Short proximity of entry tear to left subclavian artery ostium
  • Initial aortic diameter ≥40 mm
  • Initial false lumen diameter ≥22 mm
  • Number/size of fenestrations between true and false lumen
  • Stent graft-induced new entry
  • Partial false lumen thrombosis

Table 2 - Indications for left subclavian artery revascularization before zone 2 thoracic endovascular aortic repair

Society for Vascular Surgery Guidelines European Society for Vascular Surgery Guideline Additional considerations
Presence of left internal thoracic artery bypass graft In patients at risk for neurologic complications Left vertebral artery originating directly from the arch
Termination of left vertebral artery at posterior inferior cerebellar artery or other discontinuity of vertebrobasilar collaterals    
Functioning arteriovenous dialysis fistula in left arm    
Prior infrarenal aortic repair with occlusion of lumbar and middle sacral arteries    
Planned long-segment (20 cm) coverage of the descending thoracic aorta where critical intercostal arteries originate    
Hypogastric artery occlusion    
Presence of early aneurysmal changes that may require subsequent therapy involving the distal thoracic aorta    

Recommendation Grading

Overview

Title

Management of Type B Aortic Dissection

Authoring Organizations

Publication Month/Year

January 25, 2022

Document Type

Guideline

Country of Publication

US

Document Objectives

The STS/AATS writing group performed a systematic review and produced treatment recommendations for acute and chronic, complicated and uncomplicated type B aortic dissection. The document reviews alternate approaches and adjunctive interventions to reduce complications. Finally, the group identified the gaps in our current knowledge which should be the subject of future research.

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Hospital, Outpatient, Operating and recovery room

Scope

Management

Keywords

type b aortic dissection, TBAD

Source Citation

MacGillivray TE, Gleason TG, Patel HJ, Aldea GS, Bavaria JE, Beaver TM, et al. The Society of Thoracic Surgeons/American Association for Thoracic Surgery clinical practice guidelines on the management of type B aortic dissection. J Thorac Cardiovasc Surg. 2022;XXX:XX-XX.