Critical Review of Guidelines for Type B Aortic Dissection
Mario D’Oria, Jacob Budtz-Lilly, Kevin Mani, Péter Legeza, Gabriele Piffaretti, Mohamad Bashir, Matti Jubouri, Giovanni Tinelli, Salvatore T. Scali
Abstract
The management of type B aortic dissection is one of the most challenging and debated topics in contemporary cardiovascular surgery practice. Patients with acute or chronic dissection-related complications face high morbidity and mortality if not treated promptly. For most patients requiring intervention, thoracic endovascular aortic repair (TEVAR) is considered the gold standard. However, both early and late TEVAR-related complications make decision-making complex, even for experienced clinicians. In many cases, optimal medical management with longitudinal imaging surveillance may be preferred. In response to these challenges, several societal guidelines have recently been published to provide evidence-based or expert consensus "best practice" recommendations. Although these guidelines share many commonalities, they also highlight key unresolved clinical questions. For example, debates persist over the appropriate use of TEVAR for "uncomplicated" TBAD, defining "high-risk" criteria for uncomplicated presentations, and management of the false lumen, among other topics. Despite recent updates, a critical evaluation of the nuanced differences between these guidelines is lacking. Therefore, the purpose of this review is to compare current clinical practice guidelines, highlight their similarities and differences, and offer a comprehensive evaluation of the evidence surrounding management of TBAD. Moreover, this analysis will provide recommendations to address important knowledge gaps.