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January 25, 2022

STS and AATS Publish New Practice Guideline for Type B Aortic Dissection

January 25, 2022—The Society of Thoracic Surgeons (STS) announced that STS and the American Association for Thoracic Surgery (AATS) have published a new clinical practice guideline that includes recommendations for managing patients with type B aortic dissection (TBAD). The guideline by Thomas E. MacGillivray, MD, et al is available online in STS’s The Annals of Thoracic Surgery and AATS’s The Journal of Thoracic and Cardiovascular Surgery.

According to STS, the new clinical practice guideline offers evidence-based recommendations that include employing a “stepwise approach” to the evaluation and treatment of patients with uncomplicated (not immediately life-threatening) TBAD, followed by close clinical surveillance.

“There has been an explosion of information in the form of research reports of varying quality regarding the treatment of type B dissection over the past decade,” commented guideline author G. Chad Hughes, MD, in the societies’ announcement. Dr. Hughes, who is from Duke University Medical Center in Durham, North Carolina, continued, “This guideline is unique in providing surgeons with a comprehensive, up-to-date summary of the state of the evidence, while also serving as ‘guard rails’ that outline treatment options and best practices in certain scenarios. This is a first for any document in the field of type B dissection management.”

The STS press release noted that according to the guideline (and historically), aggressive medical therapy is the first step and considered the gold standard for managing patients with uncomplicated TBAD, whereas open surgery should be reserved for complicated (life-threatening) cases.

However, in the past decade, the technology and techniques for treating TBAD have evolved rapidly, particularly in terms of less-invasive treatment options for the disease.

Dawn S. Hui, MD, a guideline author from The University of Texas Health Science Center at San Antonio, Texas, advised in the press release that one of the most significant standouts in the guideline is the new role of earlier endovascular treatment such as thoracic endovascular aortic repair (TEVAR) in patients with uncomplicated TBAD.

Dr. Hui explained that in the early phase of treatment, surgery previously was reserved for patients who had complicated TBAD; in later phases, for patients who had progression of their disease. Now, surgeons may be able to identify subsets of patients with uncomplicated TBAD who have a higher risk of progressive disease and treat them earlier with TEVAR—before progression develops. However, this recommendation remains secondary to medical management, and patient selection still needs to be better defined in the future.

The guideline states that TEVAR or open surgery, depending on the anatomy, should be the first- line treatment for complicated TBAD patients. The collective data demonstrated improved outcomes with TEVAR for these patients compared to open surgery or medical therapy alone.

The guideline also states that for some TBAD patients (ie, those with connective tissue disorders or chronic TBAD) whose disease has progressed despite medical therapy, a “more durable” open surgical repair may be recommended over TEVAR

Dr. Hui further commented, “We expect this guideline to improve the quality of care of patients with TBAD by providing surgeons the most up-to-date summary of when and how to effectively use which therapies, whether open surgery, endovascular therapy, or a combination of the two over the lifetime of the patient.”

According to STS, the guideline steering committee outlined a systematic review and conducted an extensive literature to identify relevant evidence for the guideline. Then, the committee wrote and developed recommendations based on a comprehensive and methodical appraisal of 50 highly cited articles that were included in the final review.

“In contrast to individual studies, clinical practice guidelines are unique because they are a high-quality summary and synthesis of what is already known about this topic,” stated Dr. Hui in the press release. “Guidelines are written according to a scientifically rigorous process. Thus, they can help resolve conflicting findings of different studies or define what treatment options are best for specific circumstances.” Dr. Hui explained further that although there remain gaps in knowledge and further studies are needed, the role and timing of certain therapies are better defined with this guideline.

Dr. Hughes said that with these new guidelines, the writing group was able to see the evidence summarized in a manner that “reinforced how little we actually know about the best way to treat these patients.” More high-quality studies—namely randomized-controlled trials—are needed, he explained. He concluded, “As a surgical community, we have been saying this for a decade, but now the time has come to finally get it done.”

The societies plan to update the TBAD guideline within the next 5 years to reflect the strengthening scientific evidence, advised Dr. Hughes in the STS press release.

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