New Practice Guideline Addresses Diagnosis, Treatment of Type B Aortic Dissection
(CBS) — CHICAGO (CBS) — The Society of Thoracic Surgeons (STS) and the American Association for Thoracic Surgery (AATS) have released a new clinical practice guideline for managing patients with type B aortic dissection (TBAD). The advice was published today in the Annals of Thoracic Surgery and The Journal of Thoracic and Cardiovascular Surgery.
"There has been a boom of knowledge in the form of varying quality research papers about the treatment of type B dissection during the last decade," stated G. Chad Hughes, MD, of Duke University Medical Center in Durham, North Carolina. "This guideline is unique in that it offers surgeons a comprehensive, up-to-date assessment of the current state of the evidence, as well as 'guard rails' that outline treatment options and suggested practices in specific scenarios." This is a first for any paper in the field of type B dissection management."
The new clinical practice guideline incorporates evidence-based recommendations such as evaluating and treating patients with simple (non-life-threatening) TBAD using a "stepwise approach," followed by close clinical surveillance.
Aortic dissection is a serious condition that can be fatal if not treated promptly. The aorta is the largest and most important artery in the body, transporting oxygen-rich blood from the heart to all of the body's organs and tissues. A dissection occurs when a tear appears in the aorta's wall. The wall is made up of three layers, and the tear separates them by allowing blood to flow between the center and outside layers (dissect). The tear's location is classified as "Type B." In a type B dissection, the tear starts in the lower (descending) segment of the aorta in the chest and might spread into the abdomen.
According to the advice (and precedent), for those with simple TBAD, intensive pharmacological therapy should be utilized first and is considered the gold standard, whereas open surgery should only be done in life-threatening circumstances. However, in the recent decade, TBAD therapy technology and techniques have evolved significantly, particularly in terms of less invasive treatment options.
"One of the most noteworthy standouts in the guideline is the new role of earlier endovascular treatment such as thoracic endovascular aortic repair (TEVAR) in patients with uncomplicated TBAD," says author Dawn S. Hui, MD, of The University of Texas Health Science Center at San Antonio.
According to Dr. Hui, surgery was previously reserved for patients with challenging TBAD early in their treatment and for patients with disease progression later in their treatment. Surgeons may now be able to identify subsets of uncomplicated TBAD patients who are at a higher risk of developing the disease and treat them with TEVAR before the disease worsens. However, this recommendation is still secondary to medical management, and future patient selection will need to be defined.
According to the guideline, TEVAR or open surgery, depending on the anatomy, should be the first-line treatment for problematic TBAD patients. According to the pooled data, TEVAR had better outcomes for these individuals than open surgery or pharmacological therapy alone.
According to the guideline, some TBAD patients (those with connective tissue disorders or chronic TBAD) whose condition has progressed despite medicinal therapy may benefit from a "more durable" open surgical repair than than TEVAR.
Dr. Hui stated, "We expect this guideline to improve the quality of treatment for patients with TBAD by providing surgeons with the most up-to-date summary of when and how to employ specific therapies, whether open surgery, endovascular therapy, or a combination of the two, over the course of the patient's lifetime."
STS believes that combining current scientific findings into clinical practice guidelines and recommendations can assist enhance surgical outcomes and the quality of patient care. In this example, a guideline steering group outlined a systematic review and conducted an extensive literature search to uncover relevant material. The panel then wrote and produced recommendations based on a thorough and meticulous review of the 50 highly cited articles included in the final report.
"Unlike individual research," Dr. Hui added, "clinical practice recommendations provide a high-quality overview and synthesis of what is already known in this domain." "A scientifically sound technique is used to produce guidelines. As a result, they can help resolve conflicting data from different studies or determine which treatment options are best for certain conditions."
The writing group was able to see the findings described in a way that "proved how little we actually know about the best way to manage these patients" using the new guidelines, according to Dr. Hughes. He went on to say that more high-quality research, specifically randomized-controlled trials, is needed. These are studies in which patients are assigned to one of two therapies at random and then monitored over time to evaluate which one is best for them in the long run.
"As a surgical community, we've been saying it for a decade, but now is the time to actually do it," Dr. Hughes said, adding that the goal is to update the TBAD guideline within the next five years to reflect the accumulating scientific evidence.
While there are still gaps in the data and further study is needed, Dr. Hui noted that this guideline has helped to clarify the aim and timing of specific medications.
Clinical Practice Guidelines for the Management of Type B Aortic Dissection from the STS/AATS. MacGillivray TE, Gleason TG, Patel HJ, Aldea GS, Bavaria JE, Beaver TM, Chen EP, Czerny M, Estrera AL, Firestone S, Fischbein MP, Hughes GC, Hui DS, Kissoon K, Lawton JS, Pacini D, Reece TB, Roselli EE, Hughes GC, Hughes GC, Hughes GC, Hughes GC, Hughes GC DOI: 10.1016/j.athoracsur.2021.11.002. http://dx.doi.org/10.1016/j.athoracsur.2021.11.002.
STS and The Annals of Thoracic Surgery
The Society of Thoracic Surgeons is a non-profit organization that represents 7,700 cardiothoracic surgeons, researchers, and allied health care professionals from around the world who are dedicated to ensuring the best possible outcomes for heart, lung, and esophageal surgeries, as well as other chest surgical procedures. It was founded in 1964. The Society's mission is to improve cardiothoracic surgeons' ability to provide high-quality patient care via collaboration, teaching, research, and advocacy. The official journal of STS and the Southern Thoracic Surgical Association is The Annals of Thoracic Surgery. It has an impact factor of 4.33. For more information, go to sts.org.