Eric Verhoeven, MD, PhD, is the chief of vascular and endovascular surgery at Klinikum Nürnberg in Nürnberg, Germany. Dr. Verhoeven shares his thoughts on dissection outcomes in the short- and long-term, and what defines successful treatment.
What are the goals of treatment in each stage of dissection?
It is important to differentiate between acute and chronic. If you talk acute, you have to look at your patient, regulate the blood pressure and see what happens. Because there are a number of hyper-acute acute and less acute complications that can occur. The goal is really to preserve the life of the patient. So if you have the most dreadful complication or rupture, you’re going to have to stent it and see that you seal it off. If you have the other most dreaded complication, malperfusion, you’re going to stent it and try to restore blood flow to the vital organs—visceral organs and the limbs. That is the hyper-acute treatment that those patients need.
If patients continue to have pain, if patients are difficult to manage with the blood pressure, if patients develop pleural effusion—and there are a few more of these soft end points—we will probably treat these patients still by TEVAR. And when I say TEVAR, it’s the first step. There are always additional steps or techniques coming at hand—petticoat, stabilize, additional stenting, additional cuffing, etc. Those patients we will also treat by TEVAR, but if possible, in the sub-acute phase. We will try to wait at least two weeks.
Every time you have to balance the benefits of waiting and having a safer procedure versus the risk of a soft endpoint becoming a hard endpoint, or a low-grade complication becoming a dramatic complication. That’s the game we play in the acute and sub-acute phase. Once the patients are treated, even if its medically and go home, after one, two, or three weeks, we will follow them.
In the chronic phase, we’re really discussing patients who have developed aneurysms—post-dissection aneurysms. There you treat the aneurysm. So you treat the risk of rupture, and you are working in a more difficult environment.
Due to the progressive nature of dissection, should we talk about secondary intervention or staged procedure in these patients?
I don’t think we should talk about staged procedures, because an intervention for a post-dissection aneurysm can occur twelve years after the initial acute dissection. Everything is possible, but I don’t think we should talk about staged procedures. We should talk about the aim to have the patient survive and be well perfused in the acute phase, and then see what happens. If you want to discuss new technical options to prevent that progression to aneurysms, we can do that. But that, of course, needs to be discussed and needs to be proven before we can say that we need to do that, and that we will not need the second step—not staged, but the secondary procedure or the treatment for the late complication. The one late complication as I said before is aneurysm formation. It is very rare to see a rupture or malperfusion in the sub-acute and later phase. Well, in sub-acute you can but in the initial chronic phase, you don’t see those complications. It’s really aneurysms, but difficult ones—post-dissection aneurysms.
Would you say that there are uncomplicated dissections?
Up to now we discussed complications. We discussed heart complications, more dramatic complications, and softer complications or more chronic-like complications—so not things that need an acute reaction from the doctor. If you discuss the patients that have no complications at all, what we call the uncomplicated, there you have to choose between TEVAR also in the sub-acute phase when it’s safer or best medical treatment.
We have defined a number of anatomical criteria from whom we know patients are at higher risk for developing those aneurysms—those post-dissection aneurysms. Those are the patients that will maybe benefit more from treatment with TEVAR in the sub-acute phase. Of course, we have to balance that with the risks of the treatments. Those uncomplicated patients or uncomplicated patients with anatomical features that probably classify them into high-risk to post-dissection evolution or progression—those patients we usually treat in the sub-acute phase.
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Eric Verhoeven, MD, PhD, is a paid consultant of Cook Medical.