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Surgical and endovascular management of type B aortic dissection

Author
James H Black, III, MD
Section Editors
Joseph L Mills, Sr, MD
John F Eidt, MD
Gabriel S Aldea, MD
Edward Verrier, MD
Deputy Editor
Kathryn A Collins, MD, PhD, FACS

INTRODUCTION

The incidence of acute aortic dissection is estimated to be 5 to 30 cases per million population [1]. Type B aortic dissections are those that originate in the descending thoracic and/or abdominal aorta (distal to the left subclavian artery) (figure 1). The primary treatment of uncomplicated type B aortic dissection remains medical [2,3], derived from the early experience in the 1960s that suggested better outcomes with medical management compared with surgery [4,5]. The goals of initial medical treatment of uncomplicated type B dissection are to stabilize the hemodynamics to minimize the extent of the dissection, reduce intimal flap mobility, and decrease the risk of rupture. For patients with uncomplicated type B dissection, mortality is low at 1 to 2 percent with medical therapy [6]. Untreated, 75 percent of patients will succumb to their aortic dissection within the first two weeks [7]. (See "Management of acute aortic dissection", section on 'Acute medical management' and "Overview of acute aortic syndromes", section on 'Acute medical management'.)

For patients who develop complications, intervention is indicated (endovascular, surgical). Patients with acute and chronic type B aortic dissection benefit from multidisciplinary management including expertise from cardiologists, vascular surgeons, cardiac surgeons, and interventional radiologists. For patients whose course is refractory to medical therapy, referral to a center with established expertise in aortopathies should be considered.

In spite of adequate medical management and surgical treatment, early mortality from type B aortic dissection remains significant, ranging from 10 to 15 percent, and contributes significantly to the overall mortality [8-11]. Since rupture is uncommon, occurring in fewer than 5 percent of all type B dissections, the majority of poor early outcomes are related to malperfusion [6,12] Long-term survival is also limited by morbidity and mortality related to aneurysmal degeneration, which occurs in up to 50 percent of patients with chronic asymptomatic type B aortic dissection with sufficient follow-up (10 years).

The endovascular and surgical management of type B aortic dissection are reviewed here. The classification, clinical features, diagnosis, and medical management of type B aortic dissection are reviewed separately. The management of type A aortic dissection is also reviewed separately. (See "Clinical features and diagnosis of acute aortic dissection" and "Management of acute aortic dissection".)

ETIOLOGY AND PATHOPHYSIOLOGY

Aortic dissection can be broadly divided into those that are sporadic, (ie, due to degenerative etiologies [atherosclerosis, inflammation/infection]), and those that are genetically-mediated whether syndromic (eg, Marfan, vascular Ehlers-Danlos, Loeys-Dietz, and Turner syndromes) or nonsyndromic (eg, familial, associated with bicuspid aortic valve). (See "Epidemiology, risk factors, pathogenesis and natural history of thoracic aortic aneurysm", section on 'Etiology and risk factors'.)

                        

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Literature review current through: Nov 2016. | This topic last updated: Tue Nov 01 00:00:00 GMT 2016.
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