Surgical Decision Making in Uncomplicated Type B Aortic Dissection: A Survey of Australian/New Zealand and European Surgeons

Bijit Munshi; Barry J Doyle; Jens C Ritter; Shirley Jansen; Louis P Parker; Vincent Riambau; Colin Bicknell; Paul E Norman; Anders Wanhainen

doi:10.1016/j.ejvs.2020.04.005

Surgical Decision Making in Uncomplicated Type B Aortic Dissection: A Survey of Australian/New Zealand and European Surgeons

Eur J Vasc Endovasc Surg. 2020 Aug;60(2):194-200. doi: 10.1016/j.ejvs.2020.04.005. Epub 2020 Jun 19.

Authors

Bijit Munshi¹, Barry J Doyle², Jens C Ritter³, Shirley Jansen⁴, Louis P Parker⁵, Vincent Riambau⁶, Colin Bicknell⁷, Paul E Norman⁸, Anders Wanhainen⁹

Affiliations

¹ Vascular Engineering Laboratory, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Australia; Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Australia; Department of Vascular Surgery, Fiona Stanley Hospital, Perth, Australia. Electronic address: bijit.munshi@gmail.com.
² Vascular Engineering Laboratory, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Australia; School of Engineering, The University of Western Australia, Perth, Australia; Australian Research Council Centre for Personalised Therapeutics Technologies, Australia; BHF Centre for Cardiovascular Science, The University of Edinburgh, UK.
³ Department of Vascular Surgery, Fiona Stanley Hospital, Perth, Australia.
⁴ Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Australia; Department of Vascular and Endovascular Surgery, Sir Charles Gairdner Hospital, Perth, Australia; Curtin Medical School, Curtin University, Perth, Australia; Heart and Vascular Research Institute, Harry Perkins Institute for Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Australia.
⁵ Vascular Engineering Laboratory, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Australia; School of Engineering, The University of Western Australia, Perth, Australia.
⁶ Vascular Surgery Division, Cardiovascular Institute, Hospital Clinic, University of Barcelona, Barcelona, Spain.
⁷ Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London, UK; Faculty of Medicine, Imperial College, London, United Kingdom.
⁸ Vascular Engineering Laboratory, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Australia; Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Australia; Department of Vascular Surgery, Fiona Stanley Hospital, Perth, Australia.
⁹ Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.

PMID: 32571654
DOI: 10.1016/j.ejvs.2020.04.005

Abstract

Objective: There is controversy about the role of pre-emptive thoracic endovascular aortic repair (TEVAR) in uncomplicated type B aortic dissection (TBAD). The aim was to understand expert opinions and the factors influencing decision making.

Methods: In 2018, surgeons from Australia/New Zealand (ANZ) and Europe (EUR) were contacted to participate in an online survey which comprised questions about preferences for pre-emptive TEVAR, followed by five case scenarios, and two ranking questions for anatomical and technical risk factors respectively. Case 1 was designed to favour TEVAR in a hypertensive patient with partial false lumen thrombosis and large diameter (aortic ≥ 40 mm, false lumen ≥ 22 mm). Case 2 had no risk factors mandating TEVAR, according to current evidence. Cases 3, 4, and 5 were designed to test one risk factor respectively, large entry tear on the inner aortic curvature (≥10 mm), partial false lumen thrombosis, and large diameter alone.

Results: There were 75 responses, 42 from EUR and 33 from ANZ. Almost half of surgeons (49.3%) endorsed pre-emptive TEVAR with 82.3% preferring to perform TEVAR in the subacute phase. In Case 1 and 5, 58.3% and 52.8% of surgeons respectively chose TEVAR, the highest rates obtained in the survey. Cases 1 and 5 included large diameters ≥40 mm, which were ranked the highest in importance when surgeons considered anatomical risk factors. Surgeons who recommend pre-emptive TEVAR were more likely to choose TEVAR in both Case 1 (83.3% vs. 33.3%, p < .001, 95% CI 27.6%-65.8%) and Case 5 (69.4% vs. 38.2%, p = .008, 95% CI 8.2%-50.0%).

Conclusion: In this survey about uncomplicated TBAD, about half of surgeons recommended pre-emptive TEVAR in selected cases. The surgeon's predisposition towards intervention and large diameters appear to be the most influential factors in decision making. These findings underline the uncertainty in today's practice and emphasise the need for better predictive tools.

Keywords: Dissecting aneurysm; Endovascular procedures; Risk; Surveys and questionnaires.

Publication types

Multicenter Study

MeSH terms

Aortic Aneurysm, Thoracic / diagnostic imaging
Aortic Aneurysm, Thoracic / surgery*
Aortic Dissection / diagnostic imaging
Aortic Dissection / surgery*
Australia
Blood Vessel Prosthesis
Blood Vessel Prosthesis Implantation* / adverse effects
Blood Vessel Prosthesis Implantation* / instrumentation
Clinical Decision-Making*
Endovascular Procedures* / adverse effects
Endovascular Procedures* / instrumentation
Europe
Health Care Surveys
Health Status
Healthcare Disparities
Humans
New Zealand
Patient Selection
Practice Patterns, Physicians'*
Risk Factors
Stents
Surgeons*
Treatment Outcome