Heart Sci J 2020; 1(3): 36-40
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Heart Science Journal
Journal Homepage : www.heartscience.ub.ac.id

Case Report

Management of Acute Uncomplicated Stanford B Aortic Dissection
in The Era of Endovascular Repair: A Case Report
Putri Annisa Kamilla1* , Novi Kurnianingsih2 , Sasmojo Widito2 , Djanggan Sargowo2 , Budi Satrijo2
1

Brawijaya Cardiovascular Research Center, Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Brawijaya, Malang, Indonesia.

2 Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Brawijaya, Malang, Indonesia.

ARTI C LE I NFO

AB STR A C T

Keywords:
Critical limb ischemia;
Endovascular stenting;
Superficial femoral artery

Background: Critical limb ischemia (CLI) is a terminal stage of peripheral arterial disease (PAD), in the absence
of intervention, may lead to lower extremity amputation or death. In cases where medical management is not
effective or severe cases of PAD, endovascular and surgical interventions are indicated. Endovascular interventions have become the first-line approach of CLI management and advanced considerably within the past decade.
Case Description: A 78 years old patient with hypertension was admitted to the hospital with persistent chest
discomfort and cough for two weeks. The CT aortic angiogram showed type B dissection. Based on the recent
guidelines, TEVAR should be considered in patients with uncomplicated type B aortic dissection. Thus we
prepared the patient for TEVAR procedure. First, we established a multidisciplinary vascular team for the pre-procedural preparation of the patient. We perform careful measurement through detailed CT angiography
reconstruction from carotid to femoral arteries. We found proximal diameter was 30-35mm, the distal diameter
was 23mm, and the landing zone right after the left brachial ostium, suitable for stent-graft Valiant Captivia
36-32x150mm. The CT also showed that both the femoral artery were normal. We decided to use the right
femoral artery as access. We proceed to the procedure two days later, under general anaesthesia, digital subtraction angiography revealed dissection of the descending aorta, and the selected device was inserted. Total
occlusion of the primary intimal tear was revealed due to the subsequent contrast injection. The patient was
transferred to ICU for postprocedural care and extubated the day after. The hospital stay was uneventful, and a
one-month follow-up CT shows no endoleak.
Conclusion: Management of uncomplicated Stanford B dissections is very challenging. TEVAR has emerged as an
alternative with lower mortality and morbidity rates compared to surgery that might offer good long-term results

DeBakey classification and the Stanford classification (Figure 1). Aorta
distal to the left subclavian artery was involved in DeBakey III or also
known as Stanford type B dissection without any retrograde extension
into the ascending aorta. Whereas in Stanford A and De Bakey I and II,
there is the involvement of ascending aorta.3,4 Based on the onset,
presentation occurs within 14 days is classified as acute, while chronic
is more than two weeks.5,6 A recent publication from the IRAD study
introduced a new classification for dissection, which stated that
symptoms onset that lasts for more than 30 days is considered as
chronic.7,8

1. Introduction
Dissection of the aorta is an uncommon yet devastating
condition presented with a broad spectrum of clinical presentations.
Population studies in the United States have estimated the incidence of
aortic dissection to range from 2 to 3.5 cases per 100,000 persons per
year.1 Aortic dissection is often associated with aging, obesity, collagen
vascular disease, etc. Due to the wide range of initial symptoms and the
physical examinations that were not specific, the use of CT, MRI, TEE,
or occasionally, intrusive aortography is needed in diagnosing aortic
dissection.

Stanford Type B aortic dissections account for 25% to 40% of
all dissections.9 The mortality rate is 11.7%, with most deaths occurring
in the first 24 hours.10 Type B aortic dissections (TBAD) can be either
complicated or uncomplicated. The following symptoms define complicated TBAD: malperfusion syndrome affecting visceral, renal,

An aortic dissection occurred when blood flow in a false
lumen between the medial and the intimal layers of the aortic wall
resulted from an intimal tear.2 The two major classifications for the
dissection of the aorta, which based on the dissection location are the

*Corresponding author at: Brawijaya Cardiovascular Research Center, Department of Cardiology and Vascular Medicine, Faculty of Medicine,
Universitas Brawijaya, Malang, Indonesia
E-mail address: putriannisamd@gmail.com (P.A. Kamilla).
https://doi.org/10.21776/ub.hsj.2020.001.03.8
Received 9 September 2020; Received in revised form 12 September 2020; Accepted 24 September 2020
Available online 21 October 2020

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Heart Sci J 2020; 1(3): 36-40

or extremity, early aortic dilatation or signs of rupture or impending
rupture (i.e., haemothorax, increasing periaortic and mediastinal
hematoma), refractory pain and hypertension despite optimal medication, or retrograde aortic dissection. When patients are asymptomatic
without pain or malperfusion signs and hemodynamically stable, the
dissection is defined as uncomplicated, constituting 75% of TBAD.11,12

persisted and rated with VAS 3-4 over 10. His was hemodynamically
stable, and there was no sign of malperfusion syndrome, rupture, or
impending rupture. Based on all of these findings patient was planned
for TEVAR procedure for acute UTBAD.

Uncomplicated type B aortic dissection (UTBAD) has been
treated conservatively with optimal medical therapy to reduce blood
pressure and heart rate. Despite the success of UTBAD optimal medical
management in the early phase, aortic degeneration and aneurysmal
development of the dissected aorta remain as a clinical problem with
the morbidity, including the aneurysm degeneration of the affected
segment, of 30% with 10% of 5-year mortality rate.13,14 Due to these
results, endovascular therapy was introduced. The thoracic endovascular aortic repair (TEVAR) of TBAD has created a paradigm shift to both
preventing and treating those complications, instead of only treating
the complications of TBAD. We present the case of a 78-year-old gentleman who presented with acute UTBAD managed by TEVAR.

We prepared this patient with our multidisciplinary vascular
team and performed detailed CT aortic angiography reconstruction to
choose the landing zone and the most suitable device for the patient.We
found proximal diameter was 30-35mm, the distal diameter was 23mm,
and the landing zone based on the intimal tear location was at the
descending part of the aorta, after the left subclavian artery branch,
suitable for stent-graft Valiant Captivia 36-32x150mm. The CT also
showed that both the femoral artery were normal. We decided to use
the right femoral artery for access (Figure 5).

3. Pre-procedural Preparation

4. Procedur
The patient was taken to the catheterization lab and prepped
and draped in the usual sterile manner from neck to knees. The patient
undergoes general anaesthesia. Digital subtraction angiography was
performed with access from the right common femoral artery. The
digital subtraction angiography (DSA) revealed the ascending aorta in
a proximal location still intact. The DSA showed intimal tear was on the
descending part of the aorta with a landing zone distal to the left
subclavian artery (Figure 6). Based on the measurement and the
landing zone, the device graft was inserted and deployed. Subsequent
contrast injection revealed total occlusion of a primary intimal tear
(Figure 7). Extravasation of contrast outside the lumen was not found.
The patient was transferred to the ICU for post-procedural care and
extubated on the same day. The rest of the hospital stay was uneventful.
The patient was discharged two days after the procedure, without any
residual chest discomfort.

Figure 1. Classification of Aortic Dissection. 17

2. Case illustrator
A 78 years-old hypertensive patient admitted to the hospital
with persistent chest discomfort and cough for two weeks. Initially, he
was admitted for suspicion of pneumonia and scheduled for a chest
x-ray by a pulmonologist. The CXR result (Figure 2) showed widened
mediastinum with the conclusion suspected aortic dissection and
pleural effusion on his left lung. He was then scheduled for a thorax
ultrasound the next day. His ultrasound result showed minimal pleural
effusion on his left lung, and due to suspicion of dissection aorta in the
CXR, the radiologist decided to evaluate the abdominal aorta and found
an intraluminal intimal flap in aorta abdominalis. Given these results,
the patient was consulted to the cardiology department and underwent
full echocardiography study, aortic duplex sonography examination,
and CT aortic angiography the next day. Echocardiography showed
mild aortic regurgitation, and the aortic duplex sonography revealed
dilatation of the descendent aorta with a size of 2.97 x 3.97 cm and
intimal flap in the abdominal aorta at the T5 level. CT aortic angiography showed TBAD from descending aorta until supra-aortic bifurcation,
with the main entry tear is renal, renal, 20-22 mm from the left subclavian artery. The maximum diameter of the descending aorta was 6.52
cm, with a false patent lumen, and the size of the false lumen was 2.64
cm. It also showed another re-entry tear later at the distal part of the
descending aorta (Figure 3). At the time of his clinical presentation, he
complained of abdominal and back discomfort that

Figure 2. CXR results showing suspicion of dilatation of the Aorta

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Heart Sci J 2020; 1(3): 36-40

Figure 3. CT Results

Figure 4. 3D CT reconstruction showing proximal to the distal landing zone.

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P.A. Kamilla, et al.

Figure 5. Digital Subtraction Angiography showed a dissection plane
with a large false lumen.

Heart Sci J 2020; 1(3): 36-40

Figure 6. DSA revealed total occlusion of the false lumen.

5. Follow up

6. Discussion

The patient came for a routine controlled each month. CT
aortic angiogram evaluation performed one month after the procedure
shows patent graft and no endoleak (Figure 8). The false lumen diameter was reduced to 20 mm with thrombus in the false lumen. The
patient was planned to undergo another serial follow-up CT aortic
angiogram in the next three months, six months, and every year. The
patient was also informed to continue anti-hypertensive drugs routinely. The patient no longer complained about the chest discomfort, and
there was no abdominal discomfort or any related neurological
symptoms.

TEVAR is a safe, minimally invasive procedure, widely used
as an alternative to surgery due to the lower morbidity and mortality
rates in selected patient groups. The rationale for TEVAR for the
management of TBAD is to promote primary closure in entry tear,
which ultimately leads to false lumen thrombosis by decreasing
pressure in the false lumen. It also prevents aortic events at the chronic
phase, such as aneurysmal formation and rupture.6
TEVAR was initially used as an alternative to surgery for
complicated Stanford B dissections, including signs of thoracic aorta
rupture, organ malperfusion, or rapid expansion of the dissection in the
distal aortic arch or the descending aorta. Later on, it has been shown
that due to a better aortic remodelling process, TEVAR also improves
long-term survival in patients with uncomplicated dissections.15 Based
on the latest ESC guidelines on the diagnosis and treatment of aortic
diseases, TEVAR should be considered in the setting of UTBAD.16
Patient selection who gain the advantage of UTBAD intervention remains as the key to maximize the benefits in aortic repair and
reduce the complications. Certain high-risk features that should prompt
repair of an acute, uncomplicated TBAD has been looked at by several
authors. These high-risk factors are as follows: intramural hematoma
with penetrating aortic ulcer in the proximal descending thoracic aorta,
initial aortic diameter > 4 cm with a false patent lumen, initial false
lumen diameter > 22 mm in the proximal descending thoracic aorta,
and recurrent or refractory pain or uncontrolled hypertension with
optimal medical therapy.11 Our patient's initial aortic diameter was 6.52
cm, and his initial false lumen was patent with a diameter of 2.64 cm,
with an intimal tear in the proximal of descending aorta, which was a
high-risk anatomic factor; the repair should have been considered at
that time.
Better clinical outcome was found in Endovascular stenting
of dissections rather than conservative treatment. The possible mechanism is likely due to the change in volume and remodelling process that
occurred after a stent is deployed. Our patient's final DSA showed
complete closure of intimal tear, thus reducing the false lumen's diameter and thrombosis. It was confirmed by a 1-month CT follow-up that
showed a patent stent with reduced false lumen to diameter 20 mm

Figure 4. 3D CT reconstruction showing proximal to the distal landing
zone.

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Heart Sci J 2020; 1(3): 36-40

P.A. Kamilla, et al.

6. Thakkar D, Dake MD. Management of type B aortic dissections:
treatment of acute dissections and acute complications from chronic
dissections. Techniques in vascular and interventional radiology
2018;21:124-30.

and no endoleaks.

7. Conclusion
When managed medically, UTBAD, a highly complicated
disease process, is correlated with poor late outcomes in a sub-group of
patients who are at risk. Its management remains a challenge in
medical practice. With improved skills and equipment, endovascular
percutaneous treatment with TEVAR emerged as an alternative to
surgery with lower morbidity and mortality rates. The first trials' results
are encouraging, suggesting that TEVAR ver effectively promotes a
successful aortic remodelling in acute and subacute TBAD, which may
be associated with reduced aorta-related complications and better
survivals.

7. Booher AM, Isselbacher EM, Nienaber CA, et al. The IRAD classification system for characterizing survival after aortic dissection. The
American journal of medicine 2013;126:730. e19-. e24.
8. Trimarchi S, Nienaber CA, Rampoldi V, et al. Role and results of
surgery in acute type B aortic dissection: insights from the International Registry of Acute Aortic Dissection (IRAD). Circulation
2006;114:I-357-I-64.
9

8. Declarations

Hughes GC, Andersen ND, McCann RL. Management of acute type
B aortic dissection. Elsevier; 2013.

10. Cooper M, Hicks C, Ratchford EV, Salameh MJ, Malas M. Diagnosis
and treatment of uncomplicated type B aortic dissection. Vascular
Medicine 2016;21:547-52.

8.1. Ethics Approval and Consent to participate
Patient has provided informed consent prior to involve in the study.
8.2. Consent for publication
Not applicable.

11. Helder MR, Bacharach JM. Evolving Technologies for the Treatment
of Type B Aortic Dissections—A Case Report and Review of the
Literature. Journal of the Minneapolis Heart Institute Foundation
2018;2:38-43.

8.3. Availability of data and materials
Data used in our study were presented in the main text.

12. Zipes DP, Libby P, Bonow RO, Mann DL, Tomaselli GF. Braunwald's
Heart Disease E-Book: A Textbook of Cardiovascular Medicine:
Elsevier Health Sciences; 2018.

8.4. Competing interests
Not applicable.
8.5. Funding source
Not applicable.

13. Suzuki T, Isselbacher EM, Nienaber CA, et al. Type-selective
benefits of medications in treatment of acute aortic dissection (from
the International Registry of Acute Aortic Dissection [IRAD]). The
American journal of cardiology 2012;109:122-7.

8.6. Authors contributions
Idea/concept: PAK. Design: PAK. Control/supervision: PAK, NK,SW.
Data collection/processing: PAK.Extraction/Analysis/interpretation:
PAK, NK, SW. Literature review: PAK, NK, SW. Writing the article: PAK.
Critical review: NK, SW. All authors have critically reviewed and
approved the final draft and are responsible for the content and similarity index of the manuscript.

14. Tsai TT, Evangelista A, Nienaber CA, et al. Long-term survival in
patients presenting with type A acute aortic dissection: insights
from the International Registry of Acute Aortic Dissection (IRAD).
Circulation 2006;114:I-350-I-6.

8.7. Acknowledgements
We thank to Brawijaya Cardiovascular Research Center.

15. Song C, Lu Q, Zhou J, et al. The new indication of TEVAR for
uncomplicated type B aortic dissection. Medicine 2016;95.

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