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Three Part Question

In [patients with subacute uncomplicated type B aortic dissection] is [endovascular or medical management] superior [with regards to long term mortality]?

Clinical Scenario

A 65 year old male presents having returned from a two week holiday. Whilst on holiday he experienced a tearing pain between his shoulder blades, which has been slow to resolve. Examination reveals no abnormal findings. However, his blood pressure in both arms is measured at 135/80. An x-ray reveals a slightly enlarged mediastinal shadow; a CT aorta is performed which confirms the diagnosis of an uncomplicated type B aortic dissection.

Search Strategy

Medline 1966 to 08/13 using the PubMed interface.
[Subacute] AND [Uncomplicated type B aortic dissection] AND [Endovascular] AND [Medical]

Search Outcome

Five papers were identified of which two met the criteria for the search question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Neinaber et al 2009 Germany	Over 2 years and across 7 centres 140 patients with subacute/ chronic uncomplicated type B aortic dissections were randomised to either endovascular or medical management	Randomised controlled trial	Primary end point was all cause death at 2 years.	There was no difference in all cause deaths with a 2 year cumulative survival rate of 95.6+/-2.5% (medical) vs 88.9+/-3.7% (TEVAR)	The trial was underpowered on the basis of previous outcome assumptions.
Fattori et al 2013 Europe	Over 6 years 6,711 type B aortic dissections. 1,548 treated medically, 1,706 had open surgery and 3,457 treated by TEVAR).	Systematic review	Early mortality (in-hospital and 30 days), early stroke and spinal chord ischaemia, long term survival and aortic event free survival.	Recommendations for subacute and chronic dissection include reserving TEVAR for complicated dissections and medical management for uncomplicated ones.	Meta analysis included patients with acute and complicated dissections. There was very limited outcome data available for subacute dissections.

Comment(s)

There are few studies in the literature that clearly define subacute type B dissection and investigate medical vs endovascular treatment. There is an abundance papers discussing the outcomes following endovascular vs surgical management, as well as the management of acute and complicated dissections. There is one large randomised trial that met the search criteria, however it was underpowered. Review of the literature reveals a need for further investigation regarding the use of TEVAR vs medical management in defined subgroups of patients with Type B dissection.

Clinical Bottom Line

Patients with subacute uncomplicated type B aortic dissections should be managed medically with TEVAR being reserved for complicated aortic dissections.

Level of Evidence

Level 1 - Recent well-done systematic review was considered or a study of high quality is available.

References

1. Neinaber CA, et al. Randomised Comparison of Strategies for Type B Aortic Dissection: The Investigation of Stent Grafts in Aortic Dissection (INSTEAD) Trial. Circulation 2009; 120(25):2519-28
2. Fattori R, et al. Interdisciplinary Expert Consensus Document on Management of Type B Aortic Dissection. J Am Coll Cardiol 2013;61(16):1661-78