Understanding acute aortic type B dissection: Are there new horizons in patient selection?

• Physical examination does not result in reliable findings.
• CTA or MRA must be performed based on availability.
• Clinical parameters at admission may contribute to patient selection.
• Flow dynamics and pressures may contribute to risk analysis of the dissection.

Aortic dissection (AD) still represents the most lethal aortic emergency. The presentation of thoracic pain of severe intensity and sudden onset is suspect for AD. Physical examination does not result in reliable findings for AD. For confirming or ruling out AD CTA or MRA must be performed; the choice should depend on the availability. Multiple studies have identified predictors of poor outcome at admission (eGFR <60 ml/min and aortic diameter ≥40 mm) and during admission (patency of the false lumen). Despite the identified predictors of poor outcome today’s treatment modality depends whether the acute type B AD (ABAD) is categorized as either uncomplicated or complicated. Open surgery is replaced by endovascular therapy (fenestration and/or endovascular stent grafting) for treatment of complicated ABAD. The treatment for uncomplicated ABAD is still medical management. Once complications occur the prognosis declines, with hospital mortality greater than 50%. The Acute uncomplicated type B Dissection Stent-grafting OR Best Medical Treatment (ADSORB) Study randomizing ABAD treated with best medical therapy with and without stent grafts may answer the question to whether early intervention in uncomplicated dissection reduces the risk of late complications. Improvement in diagnostic modalities for ABAD, in particular MRI, result in more insight in morphology and flow dynamics. More information of flow dynamics and pressures in both lumen can result in better understanding of the dissection and contribute to risk analysis of the dissection. These insights may result in better patient selection and early intervention in uncomplicated ABAD reducing morbidity and mortality.