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Management of acute aortic syndromes

Session presentations
  • Natural history. Presented by G Rocchi (Bologna, IT)See the slides
  • Predictors of complications. Presented by A Evangelista Masip (Barcelona, ES)See the slides
  • Indications for endovascular treatment. Presented by C A Nienaber (Rostock, DE)See the slides
  • Indications for surgical or hybrid intervention. Presented by M Grabenwoeger (Vienna, AT)See the slides

Guido Rocchi, Bologna, Italy- Natural history

This talk focussed on epidemiology and incidence of acute aortic syndromes, acute aortic dissection, intramural hematoma as well as penetrating atherosclerotic ulcer. The speaker focussed on the important issue of diagnostic delay, as the clinical presentation is unspecific and may well be misinterpreted as an acute coronary syndrome. This is frequently the case since both acute type A and type B aortic dissection may be associated- type A directly and type B indirectly- with ST segment changes. Furthermore, the importance of adequate diagnostics via a multislice (ideally gated) CT scan was mentioned as it serves as a triple diagnostic tool in one: acute aortic dissection, acute coronary syndrome, and pulmonary embolism. The increasing incidence of penetrating atherosclerotic ulcers was stressed, as the increase seems linked to the gradual increase of life expectancy.

Furthermore, the understanding and differentiation of penetrating atherosclerotic ulcers and atherosclerotic aneurysms was emphasized. The speaker summarized that the mortality of acute aortic syndromes without treatment, irrespective of the type of acute aortic dissection, (A or B, intramural hematoma or penetrating atherosclerotic ulcer) remains very high. The time interval between onset of symptoms and adequate diagnosis remains decisive for the initiation of adequate treatment, thereby saving lives. Finally, follow-up is crucial, implementing imaging to anticipate early and late aortic adverse events and mandatory to adequately care for these patients.

Arturo Evangelista, Barcelona, Spain, Predictors of complications

This talk started with an introduction to currently known predictors of mortality in acute type A and type B aortic dissection. The influence of false lumen status (fully thrombosed, partially thrombosed or patent) was stressed, as a partially thrombosed false lumen is known to be a predictor of early and late acute adverse aortic events. It acts as an uncontrolled state of high afterload, thereby increasing diastolic blood pressure. The important differences between the natural course of an untreated type B aortic dissection as well as a remaining type B aortic dissection after type A repair were discussed, and the reason for the better course of type B after type A was addressed. Seemingly, by surgically closing the primary entry tear- despite remaining communications between lumina- decompression is more effective and thereby the likelihood of progression is lower. A recent study addressing the importance of the location of the primary entry tear was presented, indicating that the likelihood of complicated acute type B aortic dissection rises with a shorter distance of the primary entry tear to the left subclavian artery and vice versa.

Finally, interesting approaches using functional imaging were presented. It seems obvious that applying MRI angiography as well as transesophageal echocardiography (intrathoracic pressure elevation in awake patient!!) will lead the way to a better understanding of the functional anatomy of the disease and thereby to a more individualized and thus better treatment approach. The speaker summarized that the long-term complication rate of untreated type B aortic dissection still remains high, that the maximum diameter of the primary entry tear and the proximity to the left subclavian artery predict the occurrence of complications in acute type B aortic dissection and that the combination of 3D transesophageal echo, CTA and MRI angiography will lead the way to a better understanding of these pathologies in the future.

Christoph Nienaber, Rostock, Germany, Indications for endovascular treatment

This talk started with the important fact that 30% of acute aortic syndromes are still missed at initial diagnosis, strongly affecting initial outcome. Afterwards, presenting features and other characteristics of all acute aortic syndromes were listed in detail. Cases where endotherapy was applied in acute type A aortic dissection with a localized disease pattern were presented. Then the important issue of the handling of the remaininig dissective membrane was discussed. All approaches known to date- frozen elephant trunk, uncovered stents (PETTICOAT principle) as well as off pump hybrid approaches were mentioned in both type A and type B aortic dissection. A special focus was dedicated to type B aortic dissection.

The 2 year INSTEAD results were cited not showing a survival benefit but a remodeling benefit of patients after TEVAR (thoracic endovascular aortic repair) for uncomplicated type B aortic dissection. Then, the 5 year INSTEAD results were presented showing not only a continuing remodeling benefit but also a survival benefit during long-term follow-up. However, a very liberal approach to treating each and every type B dissection prophylactically by TEVAR does not yet seem justified. Finally, it was stressed that there is no probably uncomplicated type B aortic dissection, as merely the presentation of problems alter over time, including malperfusion, impending rupture or retrograde type A aortic dissection within the first two weeks after onset and diameter progression and consequently rupture in the long run. The talk concluded that TEVAR is the therapy of first choice in complicated type B aortic dissection and may develop into the therapy of first choice in uncomplicated type B aortic dissection. Finally, TEVAR for intramural hematoma (if a primary entry tear is visible) and penetrating athersclerotic ulcers represents a viable treatment option.

Martin Grabenwoger, Vienna, Austria, Indication for surgical or hybrid intervention

This talk started with a thorough literature overview of the natural course of the remaining dissection membrane after type A repair, as well as with a huge single center series reporting favourable long-term results with regard to freedom from aortic-related death and freedom from aortic-related reintervention in the descending and thoracoabdominal aorta after the use of the frozen elephant trunk technique. The problems of "just" resecting the primary entry tear as early aneurysmal formation in the chronic remaining aortic segments was clearly highlighted. Highly vivid videos of angioscopy of the descending aorta during hypothermic circulatory arrest were presented. Thereby the audience could get an impression of the real life scenario of acute aortic syndromes- dissection, intramural hematoma as well as penetrating atherosclerotic ulcers.

It was also shown in a highly illustrative manner how the frozen elephant trunk technique remodels the descending aorta. Furthermore, a new concept of addressing acute complicated type B aortic dissections was presented, namely the primary application of the frozen elephant trunk technique in this pathology. Highly suitable candidates to date seem to be patients with a high risk of retrograde type A aortic dissection, such as patients with an ascending aortic diameter equal to or greater than 40mm, as well as patients where the anatomy or the pathology (total true lumen collapse) obviates a retrograde approach. Further studies will verify the proof of concept. Furthermore the necessity for a prospective randomized trial on additionally treating the proximal descending aorta during type A repair (frozen elephant trunk concept) versus a standard hemiarch replacement was discussed and agreed upon. Finally, innovative approaches for rerouting of supra-aortic vessels to gain a sufficient proximal landing zone for TEVAR in distal aortic arch pathology were presented. The presentation concluded by stressing the increased efficacy of the FET approach without increasing operative risk with regard to freedom from aortic related adverse events as well as freedom from the need for distal aortic reintervention. The efficacy of applying TEVAR in cases with intramural hematoma (if an even very small primary entry tear is visible) as well as in PAU was emphasized.

Overall, the session was of very high quality both in terms of the presentations and the discussion. The attendance was very good and it is clearly the case that aortic medicine garners increasing interest in the cardiological community and should therefore continue to be supported.




Management of acute aortic syndromes

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.