Aortic Dissection Clinical Practice Guidelines (STS/AATS, 2022)

Society of Thoracic Surgeons and American Association for Thoracic Surgery

These are some of the highlights of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

April 29, 2022

Clinical guidelines on the management of type B aortic dissection were published in January 2022 by the Society of Thoracic Surgeons (STS) and the American Association for Thoracic Surgery (AATS), in the Journal of Thoracic and Cardiovascular Surgery.[1]

In complicated hyperacute, acute, or subacute type B aortic dissections (TBADs) with rupture and/or malperfusion, thoracic endovascular aortic repair (TEVAR) is indicated when anatomy is favorable for such treatment.

In patients whose anatomy is unsuitable for TEVAR, consider open surgical repair for complicated hyperacute, acute, or subacute TBADs.

Evaluate and treat acute/subacute uncomplicated TBAD using a stepwise approach in which the location of the primary entry tear site is identified, the proximity and distance of the dissection to the left subclavian artery (LSA) is defined, the maximum orthogonal aortic diameter is calibrated, and a lack of any organ malperfusion or other indications of complicated disease is confirmed.

For patients with uncomplicated TBAD, treatment with optimal medical therapy (OMT) is recommended.

In patients with uncomplicated TBAD, prophylactic TEVAR may be considered to decrease late aortic-related adverse events and aortic-related death.

Consider open surgical repair for patients with chronic TBAD who have indications for intervention, unless the patient has prohibitive comorbidities.

In patients with chronic TBAD who have an indication for intervention and suitable anatomy (with an adequate landing zone and no ascending or arch aneurysm), TEVAR is a reasonable approach if comorbidities put the individuals at high risk for complications from open repair.

For more durable treatment in patients with connective tissue disorders and TBAD who, despite OMT, experience disease progression, the use of open surgical repair over TEVAR is reasonable.

Following TEVAR coverage that obstructs antegrade LSA flow, revascularization (open surgical or endovascular) of the LSA is recommended to reduce the likelihood of spinal cord ischemia (SCI).

In type B dissection patients undergoing TEVAR, if the circumstances are nonemergent and the individuals are at increased risk for SCI (eg, if coverage is >20 cm or within 2 cm of the celiac artery origin or if other risk factors exist), establishment of cerebrospinal fluid (CSF) drainage is reasonable.

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