Aortic Dissection and Complex TEVAR and TAVR

Session seeks to improve diagnoses of aortic syndromes and manage complications.

By Brenda Silva

As interest grows in vascular disease management, a targeted panel discussion offered strategies for the identification and treatment of aortic syndromes and false lumen management. The panel also looked at innovations in thoracic endovascular aortic repair (TEVAR) for complex Type B dissections. Moderator Alex Powell, MD, introduced the topic, and Michael Dake, MD, began the morning session with an explanation of how acute aortic syndromes differ in terms of their definition.

Dr. Dake suggested that the definition of acute aortic syndrome (AAS) – aortic pain with a history of hypertension – should also include ruptures. “It’s our biggest struggle and biggest mortality, and as such, we should also include it in the definition of AAS. It’s the preventable final step of aortic disease.”

He added, “With AAS, we have an unchanged mortality, but TEVAR has made a dent in the mortality rates. Diagnoses of AAS is higher than recognized and increasing, but TEVAR is having an influence. We still have more work to do with early diagnoses, but TEVAR has helped broaden eligibility, allowing more patients to be treated, and early mortality was halved compared to surgical open repair.”

Next, Frank Arko, III, MD, addressed best practices for approaching complicated Type B dissections. “When looking at Type B dissection, we have to consider patient selection and complexity, as well as facility size, physician expertise, support team, and post-op care. It is imperative that the physician, team, and facility have access to the techniques and supporting technology to complete care for the patient.”

He summed up, “TEVAR has shown significant benefits and is still the optimum treatment for Type B dissections.”

Following Dr. Arko, the next speaker addressed asymptomatic collapse of the true lumen in aortic dissection and whether there is evidence to justify endovascular therapy. Frank Criado, MD, referenced therapy options such as candy plugs, coils, and liquid embolics, and he asserted that malperfusion must always be considered as an important factor that will influence any therapy decision.

To the podium next, Gao-Jun Teng, MD, discussed uncomplicated Type B dissections with regard to TEVAR versus conservative therapy. He reported statistics showing lower hospital stays, reduced late outcomes, and better mortality rates with patients treated with TEVAR versus those treated with alternative therapy options.

Frank Arko, III, MD, returned to speak about the management of the distal false lumen in Type B dissections. He summarized that the false lumen can be addressed directly, stating, “We can seal the distal seal zone with tools that are off the shelf.”

Following next, Mark Eskandari, MD, offered insight on how to deal with uncommon complications of TEVAR-treated Type B aortic dissections. He highlighted a case that focused on stent-induced re-entry tear with multivisceral debranching chosen as the optimum therapy for the patient. A second case shown was converted to an open repair with the patient making a full recovery.

Dr. Dake then returned to the podium to look at new horizons in the treatment of aortic dissection.

“In looking to cure aortic dissection, where do we go next? How do we know which option will offer better results for any one patient? We need to look at factors such as patient selection and the size of aorta before making a decision. We also need to look at who is at higher risk of expansion, as well as look at pathological and anatomical considerations when we decide who should be treated medically.”

Dr. Dake reported that for patients with no complications and no malperfusion, 30-day mortality rates are better with TEVAR than with other options, with a longer life expectancy for patients.

“Patients must be considered on an individual basis based on if they exhibit risks. Regarding treatment options, we have nothing definitive for patients at this time. We’re heading toward a conversion of dissection to aneurysm with a Type A dissection trial beginning next month with its first patient. On the horizon, valve conduit is something to be explored, along with a focus on who should we treat and who should we treat better – we need to assess individual risk and how best to predict response to TEVAR.”

Addressing endovascular repair of traumatic aortic disruptions, James W. Dennis, MD, reported, “Endovascular repair was superior in the past, and for sizing and access considerations, it’s still the gold standard even for young people. And even though technical considerations differ, endovascular repair offers the best long-term durability in patients.”

Wrapping up the first session, Armando Lobato, MD, elaborated on the sandwich technique for complex thoracoabdominal aneurysms. He asserted that for both chimney grafts and sandwich grafts, rules need to be in place and adhered to in order know how much of a healthy neck is needed, along with similar considerations for oversizing, covered stents, and balloons.