Non-A Non-B Acute Aortic Dissection: Is There Some Confusion in the Radiologist's Mind?

Overview

Journal Tomography

Publisher MDPI

Specialty Radiology

Date 2023 Dec 22

PMID 38133078

Authors

Tullio Valente

Giacomo Sica

Federica Romano

Gaetano Rea

Roberta Lieto

Marisa De Feo

Alessandro Della Corte

Salvatore Guarino

Candida Massimo

Mariano Scaglione

Emanuele Muto

Giorgio Bocchini

Affiliations

Soon will be listed here.

Abstract

Background: The aim of this study is to define and determine the rate of acute non-A-non-B aortic dissections, and to evaluate CT angiography findings and possible complications, as well as to discuss management strategies and currently available therapy. Non-A non-B type of aortic dissection is still a grey area in the radiologist's mind, such that it is not entirely clear what should be reported and completed in terms of this disease.

Methods: A retrospective single-center study including 36 pre-treatment CT angiograms of consecutive patients (mean age: 61 years) between January 2012 and December 2022 with aortic dissection involving the aortic arch with/without the thoracic descending/abdominal aorta (type non-A non-B).

Results: According to the dissection anatomy, we identified three modalities of spontaneous acute non-A-non-B anatomical configurations. Configuration 1 ( = 25) with descending-entry tear and retrograde arch extension (DTA entry). Configuration 2 ( = 4) with Arch entry tear and isolated arch involvement (Arch alone). Configuration 3 ( = 7) with Arch entry and anterograde descending (±abdominal) aorta involvement (Arch entry). CT angiogram findings, management, and treatment options are described.

Conclusions: Acute non-A non-B dissection represents an infrequent occurrence of aortic arch dissection (with or without involvement of the descending aorta) that does not extend to the ascending aorta. The complete understanding of its natural progression, distinct CT angiography subtypes, optimal management, and treatment strategies remains incomplete. Within our series, patients frequently exhibit a complex clinical course, often necessitating a more assertive approach to treatment compared to type B dissections.

References

Augoustides J, Szeto W, Desai N, Pochettino A, Cheung A, Savino J . Classification of acute type A dissection: focus on clinical presentation and extent. Eur J Cardiothorac Surg. 2010; 39(4):519-22. DOI: 10.1016/j.ejcts.2010.05.038. View

Sun Z, Al Moudi M, Cao Y . CT angiography in the diagnosis of cardiovascular disease: a transformation in cardiovascular CT practice. Quant Imaging Med Surg. 2014; 4(5):376-96. PMC: 4213417. DOI: 10.3978/j.issn.2223-4292.2014.10.02. View

Kim J, Sundt 3rd T . Best surgical option for arch extension of type B aortic dissection: the open approach. Ann Cardiothorac Surg. 2014; 3(4):406-12. PMC: 4128934. DOI: 10.3978/j.issn.2225-319X.2014.06.02. View

Hiratzka L, Bakris G, Beckman J, Bersin R, Carr V, Casey Jr D . 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice.... Circulation. 2010; 121(13):e266-369. DOI: 10.1161/CIR.0b013e3181d4739e. View

Faggioni L, Gabelloni M . Iodine Concentration and Optimization in Computed Tomography Angiography: Current Issues. Invest Radiol. 2016; 51(12):816-822. DOI: 10.1097/RLI.0000000000000283. View

Tsai T, Isselbacher E, Trimarchi S, Bossone E, Pape L, Januzzi J . Acute type B aortic dissection: does aortic arch involvement affect management and outcomes? Insights from the International Registry of Acute Aortic Dissection (IRAD). Circulation. 2007; 116(11 Suppl):I150-6. DOI: 10.1161/CIRCULATIONAHA.106.681510. View

Schenning R, Al-Hakim R . Aortic Dissection: Branched, Fenestrated, and Parallel Aortic Stent Grafts in the Ascending Aorta and Arch. Tech Vasc Interv Radiol. 2021; 24(2):100754. DOI: 10.1016/j.tvir.2021.100754. View

Rajiah P . Updates in Vascular Computed Tomography. Radiol Clin North Am. 2020; 58(4):671-691. DOI: 10.1016/j.rcl.2020.02.011. View

Sievers H, Rylski B, Czerny M, Baier A, Kreibich M, Siepe M . Aortic dissection reconsidered: type, entry site, malperfusion classification adding clarity and enabling outcome prediction. Interact Cardiovasc Thorac Surg. 2019; 30(3):451-457. DOI: 10.1093/icvts/ivz281. View

10.

Quint L, Platt J, Sonnad S, Deeb G, Williams D . Aortic intimal tears: detection with spiral computed tomography. J Endovasc Ther. 2003; 10(3):505-10. DOI: 10.1177/152660280301000315. View

11.

Nakhaei P, Bashir M, Jubouri M, Banar S, Ilkhani S, Zare Borzeshi E . Aortic remodeling, distal stent-graft induced new entry and endoleak following frozen elephant trunk: A systematic review and meta-analysis. J Card Surg. 2022; 37(11):3848-3862. DOI: 10.1111/jocs.16918. View

12.

Bashir M, Mohammed I, Al-Tawil M, Jubouri M, Agbobu T, Chen E . Frozen elephant trunk: the gold standard. Cardiovasc Diagn Ther. 2023; 13(3):623-627. PMC: 10315428. DOI: 10.21037/cdt-23-144. View

13.

McMahon M, Squirrell C . Multidetector CT of Aortic Dissection: A Pictorial Review. Radiographics. 2010; 30(2):445-60. DOI: 10.1148/rg.302095104. View

14.

Ahmad W, Mylonas S, Majd P, Brunkwall J . A current systematic evaluation and meta-analysis of chimney graft technology in aortic arch diseases. J Vasc Surg. 2017; 66(5):1602-1610.e2. DOI: 10.1016/j.jvs.2017.06.100. View

15.

Riambau V, Bockler D, Brunkwall J, Cao P, Chiesa R, Coppi G . Editor's Choice - Management of Descending Thoracic Aorta Diseases: Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg. 2017; 53(1):4-52. DOI: 10.1016/j.ejvs.2016.06.005. View

16.

Dake M, Thompson M, van Sambeek M, Vermassen F, Morales J . DISSECT: a new mnemonic-based approach to the categorization of aortic dissection. Eur J Vasc Endovasc Surg. 2013; 46(2):175-90. DOI: 10.1016/j.ejvs.2013.04.029. View

17.

Shrestha M, Pichlmaier M, Martens A, Hagl C, Khaladj N, Haverich A . Total aortic arch replacement with a novel four-branched frozen elephant trunk graft: first-in-man results. Eur J Cardiothorac Surg. 2012; 43(2):406-10. DOI: 10.1093/ejcts/ezs296. View

18.

Kreibich M, Siepe M, Berger T, Kondov S, Morlock J, Pingpoh C . The Frozen Elephant Trunk Technique for the Treatment of Type B and Type Non-A Non-B Aortic Dissection. Eur J Vasc Endovasc Surg. 2020; 61(1):107-113. DOI: 10.1016/j.ejvs.2020.08.040. View

19.

Valentine R, Boll J, Hocking K, Curci J, Garrard C, Brophy C . Aortic arch involvement worsens the prognosis of type B aortic dissections. J Vasc Surg. 2016; 64(5):1212-1218. DOI: 10.1016/j.jvs.2016.04.054. View

20.

Rorris F, Antonopoulos C, Gissis I, Tsagakis K, Kokotsakis J . E-Vita OPEN NEO Hybrid Stent Graft: A New Frontier for Total Arch Replacement. Ann Vasc Surg. 2022; 84:211-217. DOI: 10.1016/j.avsg.2022.01.034. View