ContextAcute aortic dissection is a life-threatening medical emergency associated
with high rates of morbidity and mortality. Data are limited regarding the
effect of recent imaging and therapeutic advances on patient care and outcomes
in this setting.ObjectiveTo assess the presentation, management, and outcomes of acute aortic
dissection.DesignCase series with patients enrolled between January 1996 and December
1998. Data were collected at presentation and by physician review of hospital
records.SettingThe International Registry of Acute Aortic Dissection, consisting of
12 international referral centers.ParticipantsA total of 464 patients (mean age, 63 years; 65.3% male), 62.3% of whom
had type A dissection.Main Outcome MeasuresPresenting history, physical findings, management, and mortality, as
assessed by history and physician review of hospital records.ResultsWhile sudden onset of severe sharp pain was the single most common presenting
complaint, the clinical presentation was diverse. Classic physical findings
such as aortic regurgitation and pulse deficit were noted in only 31.6% and
15.1% of patients, respectively, and initial chest radiograph and electrocardiogram
were frequently not helpful (no abnormalities were noted in 12.4% and 31.3%
of patients, respectively). Computed tomography was the initial imaging modality
used in 61.1%. Overall in-hospital mortality was 27.4%. Mortality of patients
with type A dissection managed surgically was 26%; among those not receiving
surgery (typically because of advanced age and comorbidity), mortality was
58%. Mortality of patients with type B dissection treated medically was 10.7%.
Surgery was performed in 20% of patients with type B dissection; mortality
in this group was 31.4%.ConclusionsAcute aortic dissection presents with a wide range of manifestations,
and classic findings are often absent. A high clinical index of suspicion
is necessary. Despite recent advances, in-hospital mortality rates remain
high. Our data support the need for continued improvement in prevention, diagnosis,
and management of acute aortic dissection.

https://jamanetwork.com/journals/jama/articlepdf/192401/JOC90321.pdf

The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease.

/pdf/diagnosis-and-management-of-aortic-dissection-ol93ou3jw4.pdf

Diagnosis and management of aortic dissection

Background—Thoracic endovascular aortic repair (TEVAR) represents a therapeutic concept for type B aortic dissection. Long-term outcomes and morphology after TEVAR for uncomplicated dissection are unknown. Methods and Results—A total of 140 patients with stable type B aortic dissection previously randomized to optimal medical treatment and TEVAR (n=72) versus optimal medical treatment alone (n=68) were analyzed retrospectively for aorta-specific, all-cause outcomes, and disease progression using landmark statistical analysis of years 2 to 5 after index procedure. Cox regression was used to compare outcomes between groups; all analyses are based on intention to treat. The risk of all-cause mortality (11.1% versus 19.3%; P=0.13), aorta-specific mortality (6.9% versus 19.3%; P=0.04), and progression (27.0% versus 46.1%; P=0.04) after 5 years was lower with TEVAR than with optimal medical treatment alone. Landmark analysis suggested a benefit of TEVAR for all end points between 2 and 5 years; for example, for...

Endovascular Repair of Type B Aortic Dissection Long-Term Results of the Randomized Investigation of Stent Grafts in Aortic Dissection Trial

https://www.annalsthoracicsurgery.org/article/S0003-4975(07)02254-0/pdf

Expert consensus document on the treatment of descending thoracic aortic disease using endovascular stent-grafts.

https://www.zora.uzh.ch/id/eprint/146170/1/1-s2.0-S1078588416301782-main.pdf

Editor's Choice - Management of Descending Thoracic Aorta Diseases: Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS)

Background The treatment of thoracic aortic dissection is guided by prognostic and anatomical information. Proximal dissection requires surgery, but the appropriate treatment of distal thoracic aortic dissection has not been determined, because surgery has failed to improve the prognosis. Methods We prospectively evaluated the safety and efficacy of elective transluminal endovascular stent–graft insertion in 12 consecutive patients with descending (type B) aortic dissection and compared the results with surgery in 12 matched controls. In all 24 patients, aortic dissection was diagnosed by magnetic resonance angiography. In each group, the dissection involved the aortic arch in 3 patients and the descending thoracic aorta in all 12 patients. With the patient under general anesthesia, either surgical resection was undertaken or a custom-designed endovascular stent–graft was placed by unilateral arteriotomy. Results Stent–graft placement resulted in no morbidity or mortality, whereas surgery for type B disse...

https://www.nejm.org/doi/pdf/10.1056/NEJM199905203402003

A Pierangeli

Papers

Nonsurgical Reconstruction of Thoracic Aortic Dissection by Stent–Graft Placement