Aortic dissection reporting format: Not complicated, yet comprehensive.
August 2, 2024 by dr s venkatesan
Though foundational and prodigious, moving beyond De-bakey ,Stanford is a necessity in the management of Aortic dissections in current times. The first step is to understand the perfect 3 dimensional anatomy of entire Aorta from its origin to bifurcation and even beyond. (The 11 or12 segment demarcation of aorta is well established and gained acceptance.)
The society of vascular surgery and society for thoracic surgery has come out with land mark nomenclature in 2020.
This labeling tells us instantly about whether the dissection is A, B, or Indeterminate .It also reveal the origin of dissection, extent of dissection and the exit point, if available.
Naming & coding of Aortic dissection
Aortic dissection : Management cues
The above scheme is just a part of Initial work up with the help of MR angiogram or spiral CT. There are more critical factors like, clinical stability, time since dissection, false vs true lumen identification, its volume ,rate of propagation, branch involvement, mal-perfusion , etc need to be counted.
The curious Irony about this dreaded entity lies in the fact that in type A dissection, the surgical team need to be alerted well before they embark on this most complex cardiovascular emergency, usually in a state of the art CTVS unit. Meanwhile, most uncomplicated type B dissection demands total inactivity on the part of surgeon(as well as some cardiologists !) while the patients can be casually shifted to the intensive care ward, essentially for monitoring , bed rest and few drugs to reduce BP and shearing stress on aortic wall. The dissection can heal themselves.
The role of Interventional cardiology in Aortic dissection is evolving rapidly , still at best supportive or can buy time to bridge to surgery in some late presenting type A dissection. There has been lot of experience in some centers, where type B dissections are exclusively managed by scaffolding. But, the concern is, catheter based Interventions in low risk subsets of dissection is always a tricky decision.
Medical strategies should never be looked down upon as enemy of endovascular Interventions. So, one of the live and debatable issue is, how & where can we fit-in the hyper-talented endovascular Interventionists in the complex vascular arena of aortic dissection.
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