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Management of acute type B aortic dissection

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1 Management of acute type B aortic dissection
G. Chad Hughes, MD, Nicholas D. Andersen, MD, Richard L. McCann, MD  The Journal of Thoracic and Cardiovascular Surgery  Volume 145, Issue 3, Pages S202-S207 (March 2013) DOI: /j.jtcvs Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions

2 Figure 1 Malperfusion syndromes. A, Dynamic malperfusion results in branch vessel obstruction by the intimal flap. The degree of obstruction can vary with changes in the cardiac cycle as well as with variations in pressure in the false lumen. This type of malperfusion syndrome is generally relieved via restoration of antegrade true lumen flow. B, Computed tomographic angiogram demonstrating dynamic malperfusion of the celiac axis. C, Static malperfusion results from extension of the dissection process into the branch vessel with subsequent distal occlusion. This malperfusion syndrome is not relieved by restoration of antegrade true lumen flow and requires branch vessel stenting or surgical bypass. D, Computed tomographic angiogram demonstrating static malperfusion of the superior mesenteric artery (SMA). Note that the dissection extends out into the SMA and that both true and false lumens are occluded distally within the SMA.2,3 F = False lumen; T = true lumen. Reprinted with permission from Elsevier. The Journal of Thoracic and Cardiovascular Surgery  , S202-S207DOI: ( /j.jtcvs ) Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions

3 Figure 2 Computed tomographic angiography with 3-dimensional rendering demonstrating proximal thoracic endovascular aortic repair (TEVAR) with distal aorto-uni-iliac device placement and femoral–femoral (fem-fem) bypass for a patient with complicated acute type B dissection with long-segment unilateral iliac occlusion. EVAR, Endovascular aortic repair. The Journal of Thoracic and Cardiovascular Surgery  , S202-S207DOI: ( /j.jtcvs ) Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions

4 Figure 3 Subtraction angiography demonstrating bare-metal stenting of the superior mesenteric artery (SMA) with restoration of distal flow in a patient (computed tomographic scan shown in Figure 1, D) with acute complicated type B dissection with static SMA malperfusion. The Journal of Thoracic and Cardiovascular Surgery  , S202-S207DOI: ( /j.jtcvs ) Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions

5 Figure 4 Acute type B dissection complicated by contained rupture into the left hemithorax. The Journal of Thoracic and Cardiovascular Surgery  , S202-S207DOI: ( /j.jtcvs ) Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions

6 Figure 5 A, Intravascular ultrasound (IVUS) demonstrating true and false lumens and confirming true lumen guidewire access. B, Transesophageal echocardiography assessment of the proximal aorta at case completion demonstrating new retrograde type A dissection. The Journal of Thoracic and Cardiovascular Surgery  , S202-S207DOI: ( /j.jtcvs ) Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions

7 Figure 6 A case of type B dissection with rapid aneurysmal dilation resulting from medical noncompliance. A-C, A 30-year-old male with a history of malignant hypertension presented with an uncomplicated acute type B dissection with no high-risk anatomic features and was treated by medical management. D-F, At the 1-month follow-up visit, aortic diameters were stable but the patient's blood pressure was poorly controlled. G and H, The patient missed all subsequent follow-up appointments and re-presented 16 months later with hypertensive urgency resulting from medical noncompliance. The maximal aortic diameter was found to have enlarged by 2 cm over the 16-month interval and was treated successfully by open extent 1 thoracoabdominal aortic aneurysm (TAAA) repair. The Journal of Thoracic and Cardiovascular Surgery  , S202-S207DOI: ( /j.jtcvs ) Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions

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