Choosing the correct treatment for acute aortic type B dissection.

Acute type B aortic dissection is a life threatening disease process, which remains a clinical dilemma despite advances in technology, surgical technique and postoperative management. The variability of presenting symptoms, lack of a consensus on indications for treatment and differing opinions about the optimal timing for repair have added to the management confusion. Medical management has been the standard of care for acute uncomplicated type B dissection. Surgical repair and endovascular intervention are reserved for those who present with, or subsequently develop, dissection-related complications. Complicated dissections occur in 25% of cases and may include organ malperfusion, aortic rupture, periaortic hematoma, and uncontrolled hypertension. In the past decade thoracic endovascular aortic repair (TEVAR) has gained widespread acceptance as the modality of choice for the treatment of complicated type B dissection. This transition is representative of advances in technology, physician experience with aortic endografts and lower morbidity and mortality rates associated with TEVAR. The best medical therapy remains the standard of care for uncomplicated dissection, however this strategy fails to prevent long-term aortic-related morbidity and mortality. Recent data suggest that early TEVAR lowers aortic-related events and improves long-term aortic specific survival by covering the entry tear, promoting false lumen thrombosis and inducing aortic wall remodeling. The paucity of supporting data has created controversy surrounding the optimal treatment strategy for acute type B dissection. Nonetheless, recent healthcare trends show a paradigm shift towards the utilization of early TEVAR in acute type B dissection.

Ruptured abdominal aortic aneurysms: is open surgery an outdated operation?

The advent of endovascular aneurysm repair (EVAR) has revolutionized the treatment of abdominal aortic aneurysms. EVAR has evolved into the preferred treatment for abdominal aortic aneurysms with suitable anatomy. Several randomized clinical trials have confirmed that EVAR reduces short-term morbidity and mortality. Despite vast improvements in diagnostic imaging, open surgical repair techniques and the care of critically ill patients over the past two decades rupture of abdominal aortic aneurysms still carries an extremely high morbidity and mortality. To improve outcomes in treatment of rAAA a movement has occurred away from open repair and toward EVAR as a paradigm shift that may help to improve otherwise dismal results. In the past 10 years, numerous studies including meta-analyses, administrative databases and randomized control trials have investigated the presumed advantages of EVAR over open repair. This review summarizes the world wide experience for ruptured AAA repair and addresses the role for standardization of care with the use of aortic aneurysm protocols.