A New Morphological Variant of Acute Aortic Dissection, Non-A-Non-B Type: Choosing Treatment Strategy
Treatment of acute aortic dissection is determined by the Stanford classification which classifies all cases as type A requiring emergency surgery, and type B managed with antihypertensive therapy, and, more recently, endovascular aneurysm repair. Owing to the introduction of computed tomography (CT) and magnetic resonance imaging (MRI), a new morphological type of the disease has been identified, in which the dissection starts from the aortic arch or the first part of the descending thoracic aorta and spreads retrogradely. A new classification of acute aortic dissection – TEM (T – type, E – entry, M – malperfusion), distinguishes 3 morphological variants of the disease: type A, type B, and non-A-non-B type.
The frequency of non-A-non-B type among the other forms of acute aortic dissection is 11%. The existing classifications contain no guidelines on the management of a dissection that starts from or is limited to the aortic arch.
The aim. To outline the morphological characteristics of a new, non-A-non-B type of aortic dissection, and to determine acceptable criteria for choosing surgical procedure based on the literature review and 2 observed clinical cases.
Material and methods. During 2016-2020, two patients were classified as those having acute non-A-non-B type aortic dissection. Both patients underwent emergency surgery with total aortic arch replacement by a linear graft in one case and by a multi-branch one in the other. The patients were discharged on day 15 and 21 after surgery, respectively, without signs of heart failure or malperfusion, and with healed wounds. In neither of them a complete obliteration of the false lumen of the aorta was achieved; however, the first patient showed marked decrease in the total diameter of the descending thoracic aorta, as well as alleviation of the numbness in the right leg. The expediency of the operation in this type of dissection is explained by the fact that this morphological variant is presumably a local expansion of the type B dissection, the procedure defined as conservative by the Stanford classification. At the same time, the retrograde spreading of the dissection to the arch presents a risk of further involvement of the ascending aorta, which is another indication for surgery. Another variant of acute aortic dissection, which is morphologically similar to the non-A-non-B type, is the retrograde type A, in which surgical treatment is mostly recommended.
Conclusions. The non-A-non-B type is one of the morphological variants of acute aortic dissection which is mainly subject to emergency surgery due to the risk of potentially fatal complications. Endovascular aneurysm repair of the entire aortic arch in the non-A-non-B type aims to eliminate the initial tear of the intima. If the intimal tear is located below the orifice of the left subclavian artery, prosthetics of an arch should be supplemented with endovascular repair of the descending aorta.
- Kravchenko IM, Kravchenko VI, Osadovska IA, Larioniva OB, Tretyak OA, Lytvynenko VA, et al. [Dissecting aortic aneurysm type A: The results of long-term opytalecheniya]. Cardio-vascular surgery herald. 2016;(1(24)):101-3. Ukrainian.
- Appoo JJ, Bozinovski J, Chu MW, El-Hamamsy I, Forbes TL, Moon M, Ouzounian M, et al. Canadian Cardiovascular Society/Canadian Society of Cardiac Surgeons/Canadian Society for Vascular Surgery Joint Position Statement on Open and Endovascular Surgery for Thoracic Aortic Disease. Can J Cardiol. 2016;32(6):703-13. https://doi.org/10.1016/j.cjca.2015.12.037
- Bachet J, Teodori G, Goudot B, Diaz F, el Kerdany A, Dubois C, et al. Replacement of the transverse aortic arch during emergency operations for type A acute aortic dissection. Report of 26 cases. JTCVS. 1988;96(6):878-86.
- Berretta P, Patel HJ, Gleason TG, Sundt TM, Myrmel T, Desai N, et al. IRAD experience on surgical type A acute dissection patients: results and predictors of mortality. Ann Cardiothorac Surg. 2016 Jul;5(4):346-51. https://doi.org/10.21037/acs.2016.05.10
- Carrel T, Pasic M, Vogt P, von Segesser L, Linka A, Ritter M, et al. Retrograde ascending aortic dissection: a diagnostic and therapeutic challenge. Eur J Cardiothorac Surg. 1993;7(3):146-50;discussion 151-2. https://doi.org/10.1016/1010-7940(93)90037-c
- Easo J, Weigang E, Holzl PP, Horst M, Hoffmann I, Blettner M, et al. Influence of operative strategy for the aortic arch in DeBakey type I aortic dissection - Analysis of the German Registry for Acute Aortic Dissection Type A (GERAADA). Ann Cardiothorac Surg. 2013 Mar;2(2):175-80. https://doi.org/10.3978/j.issn.2225-319X.2013.01.03
- Elefteriades JA. What operation for acute type A dissection? JTCVS. 2002 Feb;123(2):201-3. https://doi.org/10.1067/mtc.2002.120330
- Erbel R, Aboyans V, Boileau C, Bossone E, Bartolomeo RD, Eggebrecht H, et al. 2014 ESC guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. Eur Heart J 2014;35(41):2873-926. https://doi.org/10.1093/eurheartj/ehu281
- Kazui T, Tamiya Y, Tanaka T, Komatsu S. Extended aortic replacement for acute type A dissection with the tear in the descending aorta. JTCVS. 1996;112(4):973-8. https://doi.org/10.1016/S0022-5223(96)70097-1
- Kim JB, Sundt TM 3rd. Best surgical option for arch extension of type B aortic dissection: the open approach. Ann Cardiothorac Surg. 2014 Jul;3(4):406-12. https://doi.org/10.3978/j.issn.2225-319X.2014.06.02
- Lansman SL, Raissi S, Ergin MA, Griepp RB. Urgent operation for acute transverse aortic arch dissection. JTCVS. 1989;97(3):334-41.
- Lansman SL, McCullough JN, Nguyen KH, Spielvogel D, Klein JJ, Galla JD, et al. Subtypes of acute aortic dissection. Ann Thorac Surg. 1999;67(6):1975-8; discussion 1979-80. https://doi.org/10.1016/s0003-4975(99)00419-1
- Matalanis G, Ip S. Total aortic repair for acute type A aortic dissection: a new paradigm. J Vis Surg. 2018;4:79. https://doi.org/10.21037/jovs.2018.04.04
- Nauta FJ, Tolenaar JL, Patel HJ, Appoo JJ, Tsai TT, Desai ND, et al. Impact of retrograde arch extension in acute type B aortic dissection on management and outcomes. Ann Thorac Surg. 2016;102(6):2036-43. https://doi.org/10.1016/j.athoracsur.2016.05.013
- Roberts CS, Roberts WC. Aortic dissection with the entrance tear in transverse aorta: analysis of 12 autopsy patients. Ann Thorac Surg. 1990;50(5):762-6. https://doi.org/10.1016/0003-4975(90)90681-U
- Rylski B, Perez M, Beyersdorf F, Reser D, Kari FA, Siepe M, Czerny M. Acute non-A non-B aortic dissection: incidence, treatment and outcome. Eur J Cardiothorac Surg. 2017 Dec 1;52(6):1111-7. https://doi.org/10.1093/ejcts/ezx142
- von Segesser LK, Killer I, Ziswiler M, Linka A, Ritter M, Jenni R, et al. Dissection of the descending thoracic aorta extending into the ascending aorta. A therapeutic challenge. JTCVS. 1994;108(4):755-61. https://doi.org/10.1016/S0022-5223(94)70304-3
- Kaji S, Akasaka T, Katayama M, Yamamuro A, Yamabe K, Tamita K, Akiyama M, et al. Prognosis of retrograde dissection from the descending to the ascending aorta. Circulation. 2003 Sep 9;108(Suppl 1):II300-6. https://doi.org/10.1161/01.cir.0000087424.32901.98
- Smith HN, Boodhwani M, Ouzounian M, Saczkowski R, Gregory AJ, Herget EJ, et al. Classification and outcomes of extended arch repair for acute type A aortic dissection: A systematic review and meta-analysis. ICVTS. 2017 Mar 1;24(3):450-9. https://doi.org/10.1093/icvts/ivw355
- Trivedi D, Navid F, Balzer JR, Joshi R, Lacomis JM, Jovin TG, et al. Aggressive aortic arch and carotid replacement strategy for type a aortic dissection improves neurologic outcomes. Ann Thorac Surg. 2016 Mar;101(3):896-903; Discussion 903-5. https://doi.org/10.1016/j.athoracsur.2015.08.073
- Uchida N, Shibamura H, Katayama A, Shimada N, Sutoh M, et al. Operative strategy for acute type A aortic dissection: ascending aortic or hemiarch versus total arch replacement with frozen elephant trunk. Ann Thorac Surg. 2009 Mar;87(3):773-7. https://doi.org/10.1016/j.athoracsur.2008.11.061
- Urbanski PP, Wagner M. Acute non-A-non-B aortic dissection: surgical or conservative approach? Eur J Cardiothorac Surg. 2016 Apr;49(4):1249-54. https://doi.org/10.1093/ejcts/ezv301
- Yun KL, Glower DD, Miller DC, Fann JI, Mitchell RS, White WD, et al. Aortic dissection resulting from tear of transverse arch: is concomitant arch repair warranted? JTCVS. 1991;102(3):355-68; discussion 368-70. https://doi.org/10.1016/S0022-5223(19)36518-3