Eric Verhoeven, MD, PhD, is the chief of vascular and endovascular surgery at Klinikum Nürnberg in Nürnberg, Germany. Dr. Verhoeven shares his advice for fellows who want to get experience treating dissections.
What advice do you have for fellows coming out of their programs that don’t have much experience treating dissection patients?
It’s a very interesting question. When I was a fellow, during one of my first night shifts, I got a dissection patient and I had no clue what to do. I was in the north of the Netherlands in Groningen and I started asking people. And I was amazed to see how little people knew of the pathology and how little good advice I got.
I started trying to learn about dissections. I followed and read what the IRAD group and Christoph Nienaber were doing, and later what Santi Trimarchi was doing. In the meetings, I started going to the dissection sessions, and I developed more and more interest for the pathology. Before long, in the northeast of the Netherlands, I became the “dissection specialist” and colleagues happily started sending their patients to me.
It was also the time that endovascular treatment came along, with first generation thoracic stent grafts, and we started stenting complicated dissections. We had problems as the grafts were not specifically designed for dissections, we saw new complications, but we also started seeing successes. And that’s how we learned—bit by bit.
Nowadays, we have dissection sessions in every single meeting, so you can learn from the meetings. Literature is also accumulating with a number of very good reviews. We also recently published a treatment algorithm article on the treatment of acute and subacute dissections. The main difficulty is to discern which patients to treat and when, as this is a quickly moving target.
What is the line between uncomplicated and complicated? What is uncomplicated but at risk for later problems? And does this deserve treatment? And when?
If it is an upfront complicated dissection (rupture, malperfusion) the choice is easy: endovascular treatment immediately. The problem is usually not how to start or the proximal end but the complex additional steps that may be needed. It is best to be able to choose from a whole toolbox to achieve success. This requires experience and the availability of back-up materials.
If the dissection is uncomplicated, the patient can be treated conservatively, but with strict application of antihypertensive medication on an intensive care unit for several days. CT control should be effectuated within a few days. If “weak” complications occur or anatomical features arise that predict later complications, and the patient is suitable for TEVAR, it is advisable to try to wait 2-6 weeks and then treat the patient. As I said before it is a quickly evolving field, and we tend to stent more patients, also because companies like Cook work hard to provide dissection-specific devices.
No doubt is it a complex and dangerous disease for the patient, and there is clear need for further study and discussion, and input from young and eager colleagues, that will help us all to provide a better and individualized treatment for the patients.
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Eric Verhoeven, MD, PhD, is a paid consultant of Cook Medical.