Introduction
Methods
Consensus process
Definition and classification
Classification according to localization of the primary entry
DeBakey classification | Stanford classification |
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Type I: primary entry in the ascending aorta with involvement of the aortic arch and the descending aorta | Stanford A: all dissections with involvement of the ascending aorta regardless of the localization of the primary entry. In most cases, this entry is also located in the ascending aorta |
Type II: primary entry in the ascending aorta without involvement of other parts of the aorta | |
Type III: primary entry in the descending aorta | Stanford B: all dissections with involvement of the descending aorta |
Type IIIa: extension to the diaphragm | – |
Type IIIb: extension below the diaphragm | – |
Classification according to time of onset
Classification | Time from symptom onset |
---|---|
Acute | 1–14 days |
Subacute | 15–90 days |
Chronic | > 90 days |
Classification according to symptoms
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Malperfusion of the aortic branches (spinal, iliac, visceral, renal).
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Refractory hypertension: hypertension despite three different classes of antihypertensive medication at the maximum dosage. It is a sign of instability or renal malperfusion.
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Augmentation of the periaortic hematoma and pleural effusion in two consecutive CT scans are signs of an impending rupture.
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Patients with false lumen rupture, circulatory instability and severe hypotension should be considered as being in severe life-threatening conditions.
Complex classifications
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Duration
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Intimal tear
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Size
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Segmental extent
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Clinical complication
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Thrombosis of the false lumen
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Type (T): A, B and non-A-non‑B aortic dissections
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Entry (E): localized in Ishimaru zones 0–3 [11]
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Malperfusion (M):
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M0 – no malperfusion
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M1 – coronary malperfusion
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M2 – supra-aortic malperfusion
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M3 – spinal, visceral or iliac malperfusion
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(−) no symptoms
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(+) symptoms
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The Stanford classification is the most used classification with the highest clinical benefit.
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The TEM classification has advantages for treatment decision-making; the reporting standards have advantages during the follow-up because of the inclusion of the distal extension.
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Other classifications are used regarding clinical aspects and time between onset of symptoms and presentation.
Epidemiology and pathophysiology
Incidence
Risk factors and pathophysiology
Presenting symptoms and complications
Presenting symptoms
Symptoms | Patients with type B aortic dissection (%) |
---|---|
Most severe pain ever experienced | 88.7 |
Pain in the anterior chest or interscapular region | 88.7 |
Sudden onset of pain | 85.4 |
Moving pain | 16.8 |
Syncope | 2–6 |
Arterial hypertension | 64.6 |
Pulse deficit | 26.3 |
Widened mediastinum | 42.6 |
Complications
Malperfusion
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acute kidney injury: 17.9%
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hypotension: 9.7%
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limb ischemia: 9.5%
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mesenteric ischemia: 7.4%
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spinal ischemia: 2.5%
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rupture, hypotension or shock
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malperfusion with:
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visceral ischemia
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limb ischemia
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spinal ischemia
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high risk patients with:
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refractory pain
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refractory arterial hypertension
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rapid expansion of the aortic diameter
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Diagnostic testing
Medical history
Presenting symptoms
Biomarkers
Scoring systems and combinations of different testing methods
Preoperative examinations
Intraoperative imaging
Postoperative imaging
Treatment
Acute uncomplicated type B aortic dissection
International guidelines and expert consensus documents
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The recommendations for TEVAR in uncomplicated acute type B dissections include a primary entry tear > 10 mm, primary entry at the inner curvature, maximum total diameter > 40 mm and maximal diameter of the false lumen > 25 mm. Treatment should be performed in the chronic phase (15–90 days). Centralization of aortic treatment is recommended. One risk factor for treatment is the presence of a short distance from the primary entry to the left subclavian artery (LSA).
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To prevent late complications, an early TEVAR in selected cases can be taken into account (class IIb/level B).
Best medical treatment (BMT)
Endovascular treatment
Indication and comparison of treatment modalities
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Maximal total aortic diameter at presentation > 40 mm.
Evidence class | Evidence level | Reference | |
---|---|---|---|
Maximal total aortic diameter at presentation > 40 mm | IIA | B | |
Complete thrombosis of the false lumen | IIA | B | |
Primary entry tear > 10 mm | IIB | C | |
Partial thrombosis of the false lumen | IIB | C | |
Primary entry tear at the inner curvature | IIB | C | |
Maximal false lumen diameter at presentation > 22 mm | IIB | C | |
Ratio of true/false lumen < 0.8 | IIB | C | [137] |
Ulcer-like projections | IIB | C | |
Fibrinogen-fibrin degradation products > 20 mg/ml | IIB | C | [123] |
Number of involved side branches | IIB | C |
Maximal total aortic diameter at presentation > 40 mm: | 2 points |
False lumen lager than the true lumen: | 2 points |
Ulcer-like projections: | 1 point |
Age ≥ 70 years: | 1 point |
Acute uncomplicated type B aortic dissection
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rupture
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malperfusion with
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o ischemia of visceral organs
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o leg ischemia
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o spinal ischemia
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high-risk patients with
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o refractory pain
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o refractory hypertension
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o rapid expansion of the aortic diameter
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TEVAR vs. open repair
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Patients with acute complicated type B dissections should receive TEVAR as the first-line therapy (class I/level C).
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Open repair is an alternative treatment if TEVAR is not feasible or fails (class IIA/level C).
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For malperfusion patients, endovascular fenestration is an option (class IIA/level C).
Special techniques
Hemodynamic monitoring
Subacute type B aortic dissection
Chronic type B aortic dissection
ACCF/AHA 2010 [6] | JCS 2011 [82] | ESC 2014 [43] | ESVS 2018 [83] | SVS 2020 [69] | |
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Maximal diameter of the thoracoabdominal aorta | IB (> 55 mm) | IC (> 60 mm) | IC (> 60 mm) | IIa (> 55 mm) | No information available |
Open repair in symptomatic patients or aneurysmatic aortic dissection with low operative risk | IB | No information available | IC | IIa C | No information available |
Endovascular repair symptomatic patients or aneurysmatic aortic dissection with medium/high operative risk | IB | No information available | IC | IIa C | No information available |
Open repair
Pre-endovascular era (%) | Post-endovascular era (%) | |
---|---|---|
In-hospital mortality | 15.2 | 7.5 |
1‑year survival | 82.1 | |
3‑year survival | 74.1 | |
5‑year survival | 66.3 | |
10-year survival | 50.8 | |
Stroke | 5.3 | 5.9 |
Spinal ischemia | 4.6 | 5.1 |
Acute renal injury | 13.5 | 8.1 |
Late aortic intervention | 13.3 | 11.3 |
Endovascular treatment
Comparison of treatment
Distal stent graft-induced new entry (dSINE)
Spinal ischemia
Risk of spinal ischemia
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extensive aortic pathology/treatment (< 20 cm)
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pathologies of the thoracolumbar transition
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long clamping times in open repair
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previous aortic treatments (e.g. abdominal aortic repair)
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occlusion of collateral (e.g. hypogastric artery)
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chronic renal insufficiency
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perioperative hypotension
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female sex
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urgent repair
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COPD
Prevention of spinal ischemia
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avoidance of hypotensive phases (MAP > 90 mm Hg)
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shortest possible treatment length of the aorta
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staged approach in endovascular procedures
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revascularization of the LSA
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preservation of the hypogastric arteries
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spinal drainage
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local or systemic hypothermia in open repair
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optimizing hemoglobin values
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neurophysiologic monitoring
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perioperative coiling of spinal arteries
Spinal drainage
Neuromonitoring
Preoperative coiling of spinal arteries
Therapy of the spinal ischemia
Spinal drainage
Elevation of the systematic pressure and enhancing cardiac output
Increase of the hemoglobin level ≥ 10 g/dl
Rehabilitation
Basic recommendations for rehabilitation
Drug setting during rehabilitation
Training intensity during rehabilitation
Sociomedical assessment and professional reintegration
Older and geriatric patients with type B aortic dissection
Summary
Psyche
General comments and data regarding psychological reactions after aortic dissection
Screening for psychological comorbidity after type B aortic dissection
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depression
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anxiety disorder
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post-traumatic stress disorder (PTSD)
Comorbidity | Screening questions for medical history | Standardized questionnaires |
---|---|---|
Depression | During the past month, have you often felt sad, depressed or hopeless? In the last month, have you had significantly less desire and pleasure in things that you usually enjoy doing? | |
Generalized anxiety disorder | Do you feel nervous or tense? Do you often worry about things more than other people? Do you feel like you are constantly worried and not in control? | |
Post-traumatic stress disorder | Do you suffer from intrusive, stressful thoughts and memories of a serious event (images, nightmares, flashbacks)? (The event may also be a cardiac event or its treatment) | Impact of Event-Scale – revised (IES-R) [269] |
General recommendations for psychological comorbidities associated with a type B aortic dissection
Unmet needs
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What influence does early mobilization have on the aortic outcome and how great is the associated morbidity?
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Which risk group benefits from early endovascular treatment in acute, uncomplicated aortic dissection in terms of reducing late aortic events? How can this cohort be defined in more detail?
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What influence does IVUS have on the sizing and assessment of the true and false lumen in acute complicated aortic dissection?