Abstract:
The patients with diagnosed TBAD are initially treated with antihypertensive agents, reducing the heart rate and systolic blood pressure (Isselbacher, 2005). While the therapy of the non-complicated TBAD remains conservative to the chronic phase, the complicated TBADs are treated with TEVAR to prevent further extension and diameter progression, malperfusion, and aortic rupture in the acute phase (Onitsuka et al., 2004). The signs and symptoms which define complicated TBAD are aortic ruptures, rapid aortic expansion, malperfusion, shock, paraplegia, refractory pain, peri-aortic hematoma, and refractory hypertension (Riambau et al., 2017).
The aim of the study was to compare the aortic remodeling in the patients with TBAD treated conservatively and those treated with TEVAR in the acute phase.
All patients with TBAD admitted between 2011 and 2017 to our center with at least one CT follow-up (>6 months) were included in the current study. Group A included the conservative patients with uncomplicated TBAD, while Group B included the patients with complicated TBAD who were treated with TEVAR in the acute phase. Group A was divided into two subgroups consisting either of patients whose therapy remained conservative or those converted to TEVAR due to aortic growth in the chronic phase. The baseline CT scan and the CT of the last follow-up visit were used for three-dimensional centerline reconstruction of the aorta from the aortic valve to the 1 cm below the aortic bifurcation. Aortic diameters and aortic lengths were measured at the same anatomical landmarks in the 3D centerline reconstruction for all CT examinations (Mustafi et al., 2020).
The study included 74 patients with TBAD: 50 patients in group A and 24 patients in group B. For group A the mean duration of follow-up was 1625 ± 209 days and for group B 554 ± 129 days. The prevalence of the male gender was higher compared to the female gender (A: 77%, B: 95%; P=0.17) and the mean age in both groups was 62 years (group A 62±2; group B 62±5; P=0.99) (Mustafi et al., 2020).
In the mid-descending aorta, the aortic diameter growth rate was significantly higher in group A than in group B (A: +7 mm/year, B: -4 mm/year, P=0.003). The group B treated with TEVAR in the acute phase showed a significant increase in diameter at the celiac trunk landmark (+7±3 mm/year; P=0.023), while the diameter remained stable in the conservatively treated group A. At all other landmarks, there was no significant difference between the groups. During the follow-up period, 18 patients (36%) from conservatively treated Group A were converted to TEVAR due to aortic diameter progression. These patients showed a significant increase in the diameter of the descending aorta of 18 mm/year (P<0.001) before conversion. The proximal and mid-descending aorta showed a reduction in growth rate after conversion to TEVAR (preoperative +11 and +18 mm/year; postoperative -9 and -14 mm/year, P<0.001) (Mustafi et al., 2020).
The study showed a significant diameter reduction after TEVAR in the acute phase in the descending aorta. However, an increase in diameter was spotted at the same landmark in the conservatively treated group. Despite the significant increase in diameter before conversion, TEVAR led to the most intensive remodeling after conversion in the chronic phase (Mustafi et al., 2020).
This study indicated that TEVAR can prevent the development of thoracic aneurysms after type B dissections. Moreover, our findings underline the importance of regular follow-up examinations in all TBAD patients to prevent future complications. Patients with a prominent diameter increase in the conservative treatment arm can be early identified and subjected to TEVAR therapy, and those with TEVAR therapy in the acute phase need to be surveilled due to the risk of aortic growth in the distal (thoracoabdominal and abdominal) aortic segments.
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