Thoracic endovascular aortic repair for uncomplicated Type B aortic dissection: What is the optimal time window for intervention?

BACKGROUND

Uncomplicated Type B aortic dissection (un-TBAD) is still managed conservatively with optimal medical therapy (OMT) despite evidence in favour of thoracic endovascular aortic repair (TEVAR) for un-TBAD. OMT aims to regulate heart rate and blood pressure and patients require long-term follow-up to evaluate the extent of dissection, however, many un-TBAD patients are lost to follow-up. Several trials and observational studies evaluated the use of TEVAR in combination with OMT in un-TBAD and proved the safety, effectiveness, and comparability of TEVAR relative to OMT alone. What remains in question is the optimal time window to intervene with TEVAR. This was recently addressed in a fascinating review by Jubouri et al. AIMS: This commentary aims to discuss the recent review by Jubouri et al. which further proved that TEVAR is safe and effective in un-TABD and investigated the optimal timing of TEVAR in un-TBAD.

MATERIALS &

METHODS

We carried out a literature search using multiple electronic databases including PUBMED and Scopus in order to collate research evidence on intervention timeframe and outcomes of TEVAR in un-TBAD.

RESULTS

Performing TEVAR during the subacute phase of dissection (15-90 days since symptom onset) seems to be associated with less periprocedural complications compared to the acute phase, however, late outcomes (>30 days post-TEVAR) are comparable between the two groups and are superior to the chronic phase.

DISCUSSION: The introduction of TEVAR in un-TBAD presents a paradigm shift in the management of un-TBAD and a potential move towards becoming the gold-standard treatment option for un-TBAD. Intervening with TEVAR within the first 90 days since symptom onset (acute and subacute un-TBAD) gives favourable outcomes relative to intervention in the chronic phase of dissection (>90 days since symptom onset), this is due to the dissecting septum becoming less compliant over time.

CONCLUSION

TEVAR is a safe and effective treatment modality for un-TBAD with a survival benefit compared to OMT alone. Offering TEVAR during the subacute phase of dissection yields optimal results which are comparable to the acute phase but superior to the chronic phase.