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Correspondence

Comparing Apples to Oranges: Endovascular Management of Complicated Acute Type B Aortic Dissection

Section of Cardiovascular and Thoracic Surgery, University of Nebraska Medical Center, 982315 Nebraska Medical Center, Omaha, NE 68198-2315

(Email: akhoynezhad{at}unmc.edu).

To the Editor:

I read with interest the meta-analysis by Parker and Golledge [1] evaluating outcomes of patients with acute type B aortic dissection undergoing thoracic endovascular aortic repair (TEVAR). This is an important topic, as TEVAR has become the standard of care for complicated acute type B aortic dissection, not only in centers of excellence. The authors reviewed TEVAR studies with at least 10 patients with acute type B aortic dissections, extracting the "complicated" series from the rest of the pathologies, and entered 942 patients in the database for the meta-analysis.

As per the computational theory of mind in philosophy, if the input is flawed and inaccurate, the output will be manipulated and incorrect. This can be the case even if the computational process (meta-analysis) is correctly applied. In the review performed by Parker and Golledge [1], the following series had patients with uncomplicated acute type B aortic dissection (references 18 and 27), chronic dissection (references 15, 19, 31, 33), intramural hematoma, or penetrating aortic ulcer (reference 28). These patients make up approximately half of the entire patient population included in the meta-analysis. The blame with this inaccurate input is on our medical community by using various definitions in reporting outcomes of patients with type B aortic dissection, such as acute, chronic, and complicated dissection, as well as primary technical success and treatment failure when reporting endovascular treatment options. The dissection is considered acute if the dissection is presented within 2 weeks of the initial onset of symptoms. There are multiple reports of patients who were reported as acute type B dissection who were treated beyond 14 days [2, 3]. The term complicated dissection is defined as malperfusion syndromes, (impending) rupture, and persistent and unrelenting back pain or incontrollable hypertension despite optimal medical therapy; although a proper definition of "optimal medical treatment" is missing in the literature. Primary technical success is defined as complete exclusion of the primary tear site by the stent-graft without procedural endoleak, death, or the need for conversion to open repair [4, 5]. This is not reflected in the review by Parker and Golledge [1] either.

Furthermore, I suggest we use the Stanford criteria to define treatment failure (ie, aortic rupture, device mechanical fault, reintervention, aortic-related death, or sudden or unexplained late death at any point in the follow-up) [4]. Using similar standards in reporting these challenging clinical scenarios will allow us to compare apples with apples in the literature, compute proper output, refine indications, and ultimately improve patient outcomes.

	References

Top References

 

1. Parker JD, Golledge J. Outcome of endovascular treatment of acute type b aortic dissection Ann Thorac Surg 2008;86:1707-1712.[Abstract/Free Full Text]
2. Dake MD, Kato N, Mitchell RS, et al. Endovascular stent-graft placement for the treatment of acute aortic dissection N Engl J Med 1999;340:1546-1552.[Medline]
3. Kusagawa H, Shimono T, Ishida M, et al. Changes in false lumen after transluminal stent-graft placement in aortic dissections: six years' experience Circulation 2005;111:2951-2957.[Abstract/Free Full Text]
4. Svensson LG, Kouchoukos NT, Miller DC, et al. Society of Thoracic Surgeons Endovascular Surgery Task Force Expert consensus document on the treatment of descending thoracic aortic disease using endovascular stent-grafts Ann Thorac Surg 2008;85(Suppl 1):S1-S41.[Abstract/Free Full Text]
5. Khoynezhad A, Donayre CE, Omari BO, et al. Mid-term results of endovascular treatment of complicated acute type B aortic dissection. Presented at the 34th annual meeting of the Western Thoracic Surgical Association, June 26, 2009, Kona, Hawaii. J Thorac Cardiovasc Surg 2009(in press).

This article has been cited by other articles:

				J. Golledge and J. Parker Reply Ann. Thorac. Surg., June 1, 2009; 87(6): 2006 - 2006. [Full Text] [PDF]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Ali Khoynezhad Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Khoynezhad, A. Search for Related Content PubMed PubMed Citation Articles by Khoynezhad, A. Related Collections Great vessels Related Article