Emerging Trends in the Care of Type B Aortic Dissections.

Aortic dissection is the most common of the acute aortic syndromes. Acute aortic dissection remains a highly morbid and potentially lethal condition despite contemporary advances in medical and surgical care. Type B aortic dissection (TBAD) is classified as uncomplicated, uncomplicated with high-risk features, and complicated. The role of thoracic endovascular aortic repair (TEVAR) in uncomplicated TBAD remains uncertain and is the topic of ongoing clinical trials. In most complicated cases, TEVAR is effective at restoring visceral and extremity blood flow. TEVAR has also been shown to arrest hemorrhage in the setting of thoracic aortic rupture. TEVAR has been demonstrated to induce satisfactory remodeling in the covered segment of the thoracic aorta, but progressive enlargement of the visceral aorta has led to a variety of techniques designed to promote remodeling in the uncovered aortic segment. There is a need to better define high-risk features so that treatment can be tailored to specific clinical conditions.

Variability in the Treatment of High-Risk Type B Aortic Dissection at a Single Center.

Although there are established high-risk features in acute type B aortic dissection (TBAD), its management is variable. This study characterizes complicated, uncomplicated, and high-risk TBAD in addition to their management and outcomes to gain insight into the actual significance of these high-risk features and the reality of real-world practice in managing TBAD. A retrospective review of 62 patients was conducted. Patient demographics, management, and outcomes were characterized and evaluated with Pearson's χ2 test, Fisher's exact test, or analysis of variance. Of the 32 high-risk TBADs, 66% (n = 21) received endovascular repair, 31% (n = 10) were medically managed, and 3% (n = 1) received hybrid (open and endovascular) repair. Refractory hypertension and pain (52%, n = 11) were the most common high-risk features in patients with high-risk TBAD who received endovascular repair. A maximum aortic diameter of >40 mm (67%, n = 6) was the most common high-risk feature in patients who received medical management. The most prevalent high-risk feature for all treatment groups in the high-risk TBADs was an aortic diameter of >40 mm (n = 16; 50%). Adverse postoperative outcomes were highest in the high-risk and complicated groups with endoleak as the most common adverse outcome (high-risk 12.9%, complicated 13.6%). Of the 62 patients, 47% (n = 26) had follow-up since their admission with an average follow-up time of 69 ± 166 days. The significance of high-risk features in the management of high-risk TBAD remains unclear. This single-center experience with managing acute TBAD reveals the reality of inadequate follow-up that may be specific to this disease process. This highlights a need to direct more efforts to assess long-term outcomes after treatment.

Technique of percutaneous closure of an endovascular arteriovenous fistula created for dialysis access.

Endovascular arteriovenous fistulas (eAVFs) are a new and less invasive type of creation for dialysis access. The anastomosis for eAVFs often occurs between the ipsilateral proximal radial artery and vein or proximal ulnar artery and vein. As eAVF creations are in locations that are not traditionally used for surgical AVF creations, the question of how to approach reversal of these fistulas arises. Here we present a case of closure of an ulnar artery to ulnar vein eAVF.