6.0 Conclusions

Non-A non-B aortic dissections represent a small proportion of the total number of dissections that occur annually, and this is reflected in the quantity of studies published in the literature. By definition non-A non-B dissections fall outside of the standardised classifications for aortic dissections despite the literature showing that a significant majority of these patients have a complicated disease course which has been shown to occur more frequently than other types of aortic dissection. Studies from around the world have demonstrated that surgical intervention when compared to medical management produce far more satisfactory 30-day mortality rates, with both open surgical and endovascular techniques providing good short-term results. Despite these published findings, further large-scale prospective studies are required in order to improve our understanding of best treatment and to provide more substantial evidence for the application of different surgical techniques for this subset of aortic dissections.
Bibliography
Ahmad, W., Mylonas, S., Majd, P. and Brunkwall, J. S. (2017) ’A current systematic evaluation and meta-analysis of chimney graft technology in aortic arch diseases’, J Vasc Surg, 66(5), pp. 1602-1610.e2.
Alomari, I. B., Hamirani, Y. S., Madera, G., Tabe, C., Akhtar, N. and Raizada, V. (2014) ’Aortic intramural hematoma and its complications’,Circulation, 129(6), pp. 711-6.
Baldwin, Z. K., Chuter, T. A., Hiramoto, J. S., Reilly, L. M. and Schneider, D. B. (2008) ’Double-barrel technique for endovascular exclusion of an aortic arch aneurysm without sternotomy’, J Endovasc Ther, 15(2), pp. 161-5.
Berger, T., Kreibich, M., Morlock, J., Kondov, S., Scheumann, J., Kari, F. A., Rylski, B., Siepe, M., Beyersdorf, F. and Czerny, M. (2018) ’True-lumen and false-lumen diameter changes in the downstream aorta after frozen elephant trunk implantation’, Eur J Cardiothorac Surg, 54(2), pp. 375-381.
Berger, T., Weiss, G., Voetsch, A., Arnold, Z., Kreibich, M., Rylski, B., Krombholz-Reindl, P., Winkler, A., Mach, M., Geisler, D., Seitelberger, R., Siepe, M., Beyersdorf, F., Grabenwoeger, M., Czerny, M. and Gottardi, R. (2019) ’Multicentre experience with two frozen elephant trunk prostheses in the treatment of acute aortic dissection†’,Eur J Cardiothorac Surg, 56(3), pp. 572-578.
Brown, C. R., Chen, Z., Khurshan, F., Kreibich, M., Bavaria, J., Groeneveld, P. and Desai, N. (2020) ’Outcomes after thoracic endovascular aortic repair in patients with chronic kidney disease in the Medicare population’, J Thorac Cardiovasc Surg, 159(2), pp. 402-413.
Bünger, C. M., Kische, S., Liebold, A., Leißner, M., Glass, A., Schareck, W., Ince, H. and Nienaber, C. A. (2013) ’Hybrid aortic arch repair for complicated type B aortic dissection’, J Vasc Surg,58(6), pp. 1490-6.
Canaud, L., Ozdemir, B. A., Patterson, B. O., Holt, P. J., Loftus, I. M. and Thompson, M. M. (2014) ’Retrograde aortic dissection after thoracic endovascular aortic repair’, Ann Surg, 260(2), pp. 389-95.
Cao, P., De Rango, P., Czerny, M., Evangelista, A., Fattori, R., Nienaber, C., Rousseau, H. and Schepens, M. (2012) ’Systematic review of clinical outcomes in hybrid procedures for aortic arch dissections and other arch diseases’, J Thorac Cardiovasc Surg, 144(6), pp. 1286-300, 1300.e1-2.
Carino, D., Singh, M., Molardi, A., Agostinelli, A., Goldoni, M., Pacini, D. and Nicolini, F. (2019) ’Non-A non-B aortic dissection: a systematic review and meta-analysis’, Eur J Cardiothorac Surg,55(4), pp. 653-659.
Criado, F. J. (2007) ’A percutaneous technique for preservation of arch branch patency during thoracic endovascular aortic repair (TEVAR): retrograde catheterization and stenting’, J Endovasc Ther, 14(1), pp. 54-8.
Czerny, M., Schmidli, J., Adler, S., van den Berg, J. C., Bertoglio, L., Carrel, T., Chiesa, R., Clough, R. E., Eberle, B., Etz, C., Grabenwöger, M., Haulon, S., Jakob, H., Kari, F. A., Mestres, C. A., Pacini, D., Resch, T., Rylski, B., Schoenhoff, F., Shrestha, M., von Tengg-Kobligk, H., Tsagakis, K., Wyss, T. R., Document Reviewers, Chakfe, N., Debus, S., de Borst, G. J., Di Bartolomeo, R., Lindholt, J. S., Ma, W. G., Suwalski, P., Vermassen, F., Wahba, A. and Wyler von Ballmoos, M. C. (2019a) ’Editor’s Choice - Current Options and Recommendations for the Treatment of Thoracic Aortic Pathologies Involving the Aortic Arch: An Expert Consensus Document of the European Association for Cardio-Thoracic Surgery (EACTS) & the European Society for Vascular Surgery (ESVS)’, Eur J Vasc Endovasc Surg, 57(2), pp. 165-198.
Czerny, M., Schmidli, J., Adler, S., van den Berg, J. C., Bertoglio, L., Carrel, T., Chiesa, R., Clough, R. E., Eberle, B., Etz, C., Grabenwöger, M., Haulon, S., Jakob, H., Kari, F. A., Mestres, C. A., Pacini, D., Resch, T., Rylski, B., Schoenhoff, F., Shrestha, M., von Tengg-Kobligk, H., Tsagakis, K., Wyss, T. R. and group, E. E. s. d. (2019b) ’Current options and recommendations for the treatment of thoracic aortic pathologies involving the aortic arch: an expert consensus document of the European Association for Cardio-Thoracic surgery (EACTS) and the European Society for Vascular Surgery (ESVS)’, Eur J Cardiothorac Surg, 55(1), pp. 133-162.
Czerny, M., Schoenhoff, F., Etz, C., Englberger, L., Khaladj, N., Zierer, A., Weigang, E., Hoffmann, I., Blettner, M. and Carrel, T. P. (2015) ’The Impact of Pre-Operative Malperfusion on Outcome in Acute Type A Aortic Dissection: Results From the GERAADA Registry’, J Am Coll Cardiol, 65(24), pp. 2628-2635.
Czerny, M., Weigang, E., Sodeck, G., Schmidli, J., Antona, C., Gelpi, G., Friess, T., Klocker, J., Szeto, W. Y., Moeller, P., Pochettino, A. and Bavaria, J. E. (2012) ’Targeting landing zone 0 by total arch rerouting and TEVAR: midterm results of a transcontinental registry’,Ann Thorac Surg, 94(1), pp. 84-9.
DEBAKEY, M. E., HENLY, W. S., COOLEY, D. A., MORRIS, G. C., CRAWFORD, E. S. and BEALL, A. C. (1965) ’SURGICAL MANAGEMENT OF DISSECTING ANEURYSMS OF THE AORTA’, J Thorac Cardiovasc Surg, 49, pp. 130-49.
Deeb, G. M., Patel, H. J. and Williams, D. M. (2010) ’Treatment for malperfusion syndrome in acute type A and B aortic dissection: A long-term analysis’, J Thorac Cardiovasc Surg, 140(6 Suppl), pp. S98-S100; discussion S142-S146.
Di Bartolomeo, R., Murana, G., Di Marco, L., Pantaleo, A., Alfonsi, J., Leone, A. and Pacini, D. (2017) ’Frozen versus conventional elephant trunk technique: application in clinical practice’, Eur J Cardiothorac Surg, 51(suppl 1), pp. i20-i28.
Dohle, D. S., Tsagakis, K., Janosi, R. A., Benedik, J., Kühl, H., Penkova, L., Stebner, F., Wendt, D. and Jakob, H. (2016) ’Aortic remodelling in aortic dissection after frozen elephant trunk†’,Eur J Cardiothorac Surg, 49(1), pp. 111-7.
Donas, K. P., Torsello, G., Austermann, M., Schwindt, A., Troisi, N. and Pitoulias, G. A. (2010) ’Use of abdominal chimney grafts is feasible and safe: short-term results’, J Endovasc Ther, 17(5), pp. 589-93.
Erbel, R., Aboyans, V., Boileau, C., Bossone, E., Bartolomeo, R. D., Eggebrecht, H., Evangelista, A., Falk, V., Frank, H., Gaemperli, O., Grabenwöger, M., Haverich, A., Iung, B., Manolis, A. J., Meijboom, F., Nienaber, C. A., Roffi, M., Rousseau, H., Sechtem, U., Sirnes, P. A., Allmen, R. S., Vrints, C. J. and Guidelines, E. C. f. P. (2014) ’2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC)’, Eur Heart J, 35(41), pp. 2873-926.
Estrera, A. L., Miller, C. C., Goodrick, J., Porat, E. E., Achouh, P. E., Dhareshwar, J., Meada, R., Azizzadeh, A. and Safi, H. J. (2007) ’Update on outcomes of acute type B aortic dissection’, Ann Thorac Surg, 83(2), pp. S842-5; discussion S846-50.
Feldman, M., Shah, M. and Elefteriades, J. A. (2009) ’Medical management of acute type A aortic dissection’, Ann Thorac Cardiovasc Surg,15(5), pp. 286-93.
Frederick, J. R. and Woo, Y. J. (2012) ’Thoracoabdominal aortic aneurysm’, Ann Cardiothorac Surg, 1(3), pp. 277-85.
Gallo, A., Davies, R. R., Coe, M. P., Elefteriades, J. A. and Coady, M. A. (2005) ’Indications, timing, and prognosis of operative repair of aortic dissections’, Semin Thorac Cardiovasc Surg, 17(3), pp. 224-35.
Gawinecka, J., Schönrath, F. and von Eckardstein, A. (2017) ’Acute aortic dissection: pathogenesis, risk factors and diagnosis’,Swiss Med Wkly, 147, pp. w14489.
Greenberg, R. K., Clair, D., Srivastava, S., Bhandari, G., Turc, A., Hampton, J., Popa, M., Green, R. and Ouriel, K. (2003) ’Should patients with challenging anatomy be offered endovascular aneurysm repair?’,J Vasc Surg, 38(5), pp. 990-6.
Hayashi, H., Matsuoka, Y., Sakamoto, I., Sueyoshi, E., Okimoto, T., Hayashi, K. and Matsunaga, N. (2000) ’Penetrating atherosclerotic ulcer of the aorta: imaging features and disease concept’,Radiographics, 20(4), pp. 995-1005.
Hiratzka, L. F., Bakris, G. L., Beckman, J. A., Bersin, R. M., Carr, V. F., Casey, D. E., Eagle, K. A., Hermann, L. K., Isselbacher, E. M., Kazerooni, E. A., Kouchoukos, N. T., Lytle, B. W., Milewicz, D. M., Reich, D. L., Sen, S., Shinn, J. A., Svensson, L. G., Williams, D. M., Foundation, A. C. o. C., Guidelines, A. H. A. T. F. o. P., Surgery, A. A. f. T., Radiology, A. C. o., Association, A. S., Anesthesiologists, S. o. C., Interventions, S. f. C. A. a., Radiology, S. o. I., Surgeons, S. o. T. and Medicine, S. f. V. (2010) ’2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease: executive summary. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine’, Catheter Cardiovasc Interv, 76(2), pp. E43-86.
Huang, C., Tang, H., Qiao, T., Liu, C. and Zhou, M. (2016) ’Early Results of Chimney Technique for Type B Aortic Dissections Extending to the Aortic Arch’, Cardiovasc Intervent Radiol, 39(1), pp. 28-35.
Iafrancesco, M., Goebel, N., Mascaro, J., Franke, U. F. W., Pacini, D., Di Bartolomeo, R., Weiss, G., Grabenwöger, M., Leontyev, S. A., Mohr, F. W., Sioris, T., Jakob, H., Tsagakis, K., Registry, I. E.-v. O. and Group (2017) ’Aortic diameter remodelling after the frozen elephant trunk technique in aortic dissection: results from an international multicentre registry’, Eur J Cardiothorac Surg, 52(2), pp. 310-318.
Kefeng, Z., Xudong, P., Yongmin, L., Junming, Z., Lianjun, H., Jian, Z. and Lizhong, S. (2014) ’Hybrid operation for type B aortic dissection involving distal aortic arch’, J Card Surg, 29(3), pp. 359-63.
Kreibich, M., Berger, T., Morlock, J., Kondov, S., Scheumann, J., Kari, F. A., Rylski, B., Siepe, M., Beyersdorf, F. and Czerny, M. (2018) ’The frozen elephant trunk technique for the treatment of acute complicated Type B aortic dissection’, Eur J Cardiothorac Surg, 53(3), pp. 525-530.
Kreibich, M., Siepe, M., Berger, T., Kondov, S., Morlock, J., Pingpoh, C., Beyersdorf, F., Rylski, B. and Czerny, M. (2020) ’The Frozen Elephant Trunk Technique for the Treatment of Type B and Type Non-A Non-B Aortic Dissection’, Eur J Vasc Endovasc Surg .
Lempel, J. K., Frazier, A. A., Jeudy, J., Kligerman, S. J., Schultz, R., Ninalowo, H. A., Gozansky, E. K., Griffith, B. and White, C. S. (2014) ’Aortic arch dissection: a controversy of classification’,Radiology, 271(3), pp. 848-55.
Levy, Goyal, A., Grigorova, Y., Farci, F. and Le, J. K. (2020) ’StatPearls’, Aortic Dissection : StatPearls.
Liu, H., Shu, C., Li, X., Wang, T., Li, M., Li, Q. M., Fang, K. and Wang, S. (2015) ’Endovascular aortic repair combined with chimney technique in the treatment of stanford type B aortic dissection involving aortic arch’, Ann Vasc Surg, 29(4), pp. 758-63.
Liu, K., Zhu, C., Zheng, X., Wang, T., Xu, R., Zhu, Z., Li, D., Piao, H., Li, B., Wang, Y., Zhang, S. and Sun, W. (2020) ’A New Aortic Arch Inclusion Technique With Frozen Elephant Trunk for Type A Aortic Dissection’, Ann Surg, 271(5), pp. 978-983.
Lu, Q., Jing, Z., Zhao, Z., Bao, J., Feng, X., Feng, R. and Mei, Z. (2011) ’Endovascular stent graft repair of aortic dissection type B extending to the aortic arch’, Eur J Vasc Endovasc Surg, 42(4), pp. 456-63.
Malina, M., Resch, T. and Sonesson, B. (2008) ’EVAR and complex anatomy: an update on fenestrated and branched stent grafts’, Scand J Surg, 97(2), pp. 195-204.
Nauta, F. J., Tolenaar, J. L., Patel, H. J., Appoo, J. J., Tsai, T. T., Desai, N. D., Montgomery, D. G., Mussa, F. F., Upchurch, G. R., Fattori, R., Hughes, G. C., Nienaber, C. A., Isselbacher, E. M., Eagle, K. A., Trimarchi, S. and Investigators, I. R. o. A. A. D. I. (2016) ’Impact of Retrograde Arch Extension in Acute Type B Aortic Dissection on Management and Outcomes’, Ann Thorac Surg, 102(6), pp. 2036-2043.
Nienaber, C. A., Clough, R. E., Sakalihasan, N., Suzuki, T., Gibbs, R., Mussa, F., Jenkins, M. P., Thompson, M. M., Evangelista, A., Yeh, J. S., Cheshire, N., Rosendahl, U. and Pepper, J. (2016) ’Aortic dissection’,Nat Rev Dis Primers, 2, pp. 16071.
Pape, L. A., Awais, M., Woznicki, E. M., Suzuki, T., Trimarchi, S., Evangelista, A., Myrmel, T., Larsen, M., Harris, K. M., Greason, K., Di Eusanio, M., Bossone, E., Montgomery, D. G., Eagle, K. A., Nienaber, C. A., Isselbacher, E. M. and O’Gara, P. (2015) ’Presentation, Diagnosis, and Outcomes of Acute Aortic Dissection: 17-Year Trends From the International Registry of Acute Aortic Dissection’, J Am Coll Cardiol, 66(4), pp. 350-8.
Patel, P. D. and Arora, R. R. (2008) ’Pathophysiology, diagnosis, and management of aortic dissection’, Ther Adv Cardiovasc Dis, 2(6), pp. 439-68.
Riambau, V., Böckler, D., Brunkwall, J., Cao, P., Chiesa, R., Coppi, G., Czerny, M., Fraedrich, G., Haulon, S., Jacobs, M. J., Lachat, M. L., Moll, F. L., Setacci, C., Taylor, P. R., Thompson, M., Trimarchi, S., Verhagen, H. J., Verhoeven, E. L., Esvs Guidelines Committee, Kolh, P., de Borst, G. J., Chakfé, N., Debus, E. S., Hinchliffe, R. J., Kakkos, S., Koncar, I., Lindholt, J. S., Vega de Ceniga, M., Vermassen, F., Verzini, F., Document Reviewers, Black, J. H., Busund, R., Björck, M., Dake, M., Dick, F., Eggebrecht, H., Evangelista, A., Grabenwöger, M., Milner, R., Naylor, A. R., Ricco, J. B., Rousseau, H. and Schmidli, J. (2017) ’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, 53(1), pp. 4-52.
Rylski, B., Pérez, M., Beyersdorf, F., Reser, D., Kari, F. A., Siepe, M. and Czerny, M. (2017) ’Acute non-A non-B aortic dissection: incidence, treatment and outcome’, Eur J Cardiothorac Surg, 52(6), pp. 1111-1117.
Shrestha, M., Bachet, J., Bavaria, J., Carrel, T. P., De Paulis, R., Di Bartolomeo, R., Etz, C. D., Grabenwöger, M., Grimm, M., Haverich, A., Jakob, H., Martens, A., Mestres, C. A., Pacini, D., Resch, T., Schepens, M., Urbanski, P. P. and Czerny, M. (2015) ’Current status and recommendations for use of the frozen elephant trunk technique: a position paper by the Vascular Domain of EACTS’, Eur J Cardiothorac Surg, 47(5), pp. 759-69.
Shu, C., Luo, M. Y., Li, Q. M., Li, M., Wang, T. and He, H. (2011) ’Early results of left carotid chimney technique in endovascular repair of acute non-a-non-B aortic dissections’, J Endovasc Ther, 18(4), pp. 477-84.
Sievers, H. H., Rylski, B., Czerny, M., Baier, A. L. M., Kreibich, M., Siepe, M. and Beyersdorf, F. (2020) ’Aortic dissection reconsidered: type, entry site, malperfusion classification adding clarity and enabling outcome prediction’, Interact Cardiovasc Thorac Surg,30(3), pp. 451-457.
Urbanski, P. P., Lenos, A., Schmitt, R. and Diegeler, A. (2010) ’Extended arch resection in acute type A aortic dissection: PRO’,Cardiol Clin, 28(2), pp. 335-42.
Urbanski, P. P. and Wagner, M. (2016) ’Acute non-A-non-B aortic dissection: surgical or conservative approach?’, Eur J Cardiothorac Surg, 49(4), pp. 1249-54.
von Segesser, L. K., Killer, I., Ziswiler, M., Linka, A., Ritter, M., Jenni, R., Baumann, P. C. and Turina, M. I. (1994) ’Dissection of the descending thoracic aorta extending into the ascending aorta. A therapeutic challenge’, J Thorac Cardiovasc Surg, 108(4), pp. 755-61.
Wang, W., Piao, H., Wang, Y., Li, B., Zhu, Z., Wang, T. and Liu, K. (2020) ’Early outcomes with a hybrid technique for repair of a non-A non-B aortic dissection’, J Thorac Cardiovasc Surg .
Zhao, H. P., Zhu, J. M., Ma, W. G., Zheng, J., Liu, Y. M. and Sun, L. Z. (2012) ’Total arch replacement with stented elephant trunk technique for acute type B aortic dissection involving the aortic arch’, Ann Thorac Surg, 93(5), pp. 1517-22.
Zhu, Y., Guo, W., Liu, X., Jia, X., Xiong, J. and Wang, L. (2013) ’The single-centre experience of the supra-arch chimney technique in endovascular repair of type B aortic dissections’, Eur J Vasc Endovasc Surg, 45(6), pp. 633-8.
Ziganshin, B. A., Dumfarth, J. and Elefteriades, J. A. (2014) ’Natural history of Type B aortic dissection: ten tips’, Ann Cardiothorac Surg, 3(3), pp. 247-54.
Zou, J., Jiao, Y., Zhang, X., Jiang, J., Yang, H. and Ma, H. (2016) ’Early- and Mid-term Results of the Chimney Technique in the Repair of Aortic Arch Pathologies’, Cardiovasc Intervent Radiol, 39(11), pp. 1550-1556.