Czerny, Martin

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Dr Czerny: What were your criteria for convexity and concavity? You didn’tmention that.Dr Kitamura: We just retrospectively reviewed the CT scan. For the initialcases, it was approximately 2.5-mm slices, so we just reconstructed it.Dr Czerny: Let’s say, it’s never 90 and 270 degrees. So you draw a line?Dr Kitamura: Yes.Dr Czerny: And everything above was convexity and everything below wasconcavity?Dr Kitamura: Yes.Dr J. Bavaria (Philadelphia, PA, USA): So regarding the fact that your outer orgreater curvature had more of a problem with TEVAR, in that your TEVAR resultswere worse in your last slide than it was when the entry site was the innercurve; why? Is that just because you had a more difﬁcult time covering theprimary tear site? Did you have more type IA endoleaks? Why do you think thegreater curve is more problematic?Dr Kitamura: Well, for our previous study, the stent grafts used were mostlyhandmade ones rather than a commercially available one. So probably withthe latest generation of stent grafts the outcome would be better, but oneneeds a longer time to say anything for sure.Dr M. Grimm (Innsbruck, Austria): How does this impact on your daily doingsnow? When you have a patient presenting with an uncomplicated type B dis-section and the entry tear is in the inner curvature, you rather go for a conser-vative observation, and when the entry tear is at the outer curvature, you rathertend towards liberal TEVAR in these patients? Because this would be themessage I understand out of this.Dr Kitamura: Well, at the moment the indication for intervention is only thediameter because, looking into the data, it seemed that all the rupture caseshad aortic expansion before rupture. So probably for outer curvature entrycases, we might as well check CT or MRI more often. If the patient developssymptoms, including indeﬁnite ones, we might as well check CT or MRI toexclude rapid expansion. But the indication for intervention being a maximumaortic diameter of 55 to 60 mm would be reasonable for all cases, I think.Dr Grimm: So rather close monitoring than more aggressive treatment?Dr Kitamura: Yes.European Journal of Cardio-Thoracic Surgery 48 (2015) 662–663 EDITORIAL COMMENTdoi:10.1093/ejcts/ezu522 Advance Access publication 22 January 2015Cite this article as: Czerny M. Re: Impact of the entry site on late outcome in acute Stanford type B aortic dissection. Eur J Cardiothorac Surg 2015;48:662–3.Re: Impact of the entry site on late outcome in acute Stanford type Baortic dissectionMartin Czerny*University Clinic for Cardiovascular Surgery, University Hospital Zurich, Zurich, Switzerland* Corresponding author. University Clinic for Cardiovascular Surgery, University Hospital Zurich, Rämistrasse 100, CH-8091 Zurich, Switzerland. Tel: +41-442-551111;fax: +41-442-554467; e-mail: martin.czerny@usz.ch (M. Czerny).Keywords: Acute type B aortic dissection • Aortic event • Aortic intervention • Entry • OutcomeAcute type B aortic dissection is regarded as the ‘nice’ dissectionas it is usually not a cardiac surgical emergency and the acutephase responds well to medical therapy in a large number ofpatients. Therefore, the term ‘uncomplicated’ was attributed tothis group when compared with the ‘complicated’ ones presentingwith malperfusion, rupture or retrograde type A aortic dissection.Primary TEVAR for patients presenting with complications hasalready been established and remains the treatment of choice inthe vast majority of patients with complicated type B aortic dissec-tion. However, ‘uncomplicated’ should not be confused with‘harmless’ as many patients will develop the need for any kind oftreatment—early or late. ‘Uncomplicated’ should be used as asynonym to ‘currently not in need of intervention’ and this maychange sooner or later as shown by the present study [1].Recently, a better understanding of the natural course of thedisease has been gained and thereby a much better anticipationof the need for treatment is available. Every physician treatingpatients with acute type B aortic dissection knows the clinicalscenario of an initially very stable patient being found dead soonafterwards. Recent research has identiﬁed a new sub-group atrisk for early adverse events and thereby the location of theprimary entry tear comes into the focus of attention. It wasdemonstrated that patients with a primary entry tear located atthe concavity of the distal aortic arch have a substantially higherincidence of primary present or secondary developing compli-cations such as malperfusion or retrograde type A aortic dissec-tion/type A intramural haematoma [2]. Also the distance of theprimary entry tear to the left subclavian artery is decisive; thecloser the distance, the higher is the likelihood of already havingor developing complications [3]. Consequently, these patientsqualify for ‘early’ therapy to close the primary entry tear, aimedat prevention of these complications.Kitamura and his group now share with us their experience,identifying a primary entry tear at the convexity of the aortic arch(which is new) as well as aortic diameter (which is known) asindependent predictors of ‘late’ adverse outcome. What is notreported in their study is the time from the onset of symptoms tothe time of referral and diagnosis as patients with a primary entrytear at the concavity of the distal aortic arch may either neverhave reached a hospital as limiting complications such as severemalperfusion or retrograde type A aortic dissection might havealready occurred and thereby a natural selection process or atriage process (retrograde type A directly to cardiac surgery) mayhave already taken place.T. Kitamura et al. / European Journal of Cardio-Thoracic Surgery662Each phase of the disease process in acute type B aortic dissec-tion has its inherent complications as new onset of malperfusionor retrograde type A aortic dissection is rare after the ﬁrst 2weeks after the event. After the acute phase, the subacute andchronic phases may also challenge both patient and physician asdiameter increase in the ‘subacute’ phase is frequently observed.However, there is still a lack of evidence to show that ‘physio-logical’ diameter increase is inherent to the disease process itselfand that ‘pathological’ diameter increase warrants treatment toprevent rupture. There is ongoing research aimed at clarifyingthese questions. What is already known is that patients with anentry tear >10 mm or a false lumen diameter of >22 mm at thetime of diagnosis are at an increased risk for aneurysm develop-ment and therefore may be considered for prophylactic TEVAR[3, 4].In the chronic phase, regular visits to a dedicated aortic out-patient clinic taking care of clinical as well as imaging follow-upremain decisive as late aneurysmal dilatation remains a clinicalreality in a certain percentage of patients, who have to be moni-tored and eventually treated appropriately, as was conﬁrmedhere.In summary, the lessons from this study support the fact thatuncomplicated type B aortic dissection should not be confusedwith ‘harmless’ type B aortic dissection and clinical alertness ineach phase of the disease process is decisive. In many patients, itis not the question whether complications develop, but ratherwhen they develop. Although the incidence of severe malperfu-sion and retrograde type A aortic dissection decreases over time,there is an increasing incidence of aneurysmal degeneration.Morphological predictors of complications such as the locationof the primary entry tear, the distance to the left subclavian artery,initial aortic diameter and the size of the primary entry tearshould be actively implemented into decision-making to eitherremain with medical therapy or to advance to treatment.REFERENCES[1] Kitamura T, Torii S, Oka N, Horai T, Itatani K, Yoshii T et al. Impact of theentry site on late outcome in acute Stanford type B aortic dissection. Eur JCardiothorac Surg 2015;48:655–61.[2] Loewe C, Czerny M, Sodeck GH, Ta J, Schoder M, Funovics M et al. A newmechanism by which an acute type B aortic dissection is primarily compli-cated, becomes complicated or remains uncomplicated. Ann Thorac Surg2012;93:1215–22.[3] Evangelista A, Salas A, Ribera A, Ferreira-González I, Cuellar H, Pineda Vet al. Long-term outcome of aortic dissection with patent false lumen: pre-dictive role of entry tear size and location. Circulation 2012;125:3133–41.[4] Song JM, Kim SD, Kim JH, Kim MJ, Kang DH, Seo JB et al. Long-term predic-tors of descending aorta aneurysmal change in patients with aortic dissec-tion. J Am Coll Cardiol 2007;50:799–804.AORTICSURGERYT. Kitamura et al. / European Journal of Cardio-Thoracic Surgery 663

Re: Impact of the entry site on late outcome in acute Stanford type B aortic dissection

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Re: Impact of the entry site on late outcome in acute Stanford type B aortic dissection

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