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TEVAR for Expanding Chronic Type B — EECC MCQ

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ModerateAortic DiseaseTEVAR for Expanding Chronic Type BEECC

A 72-year-old man with type B aortic dissection that was managed medically 6 months ago returns for follow-up CT. The false lumen remains patent with the maximum descending aortic diameter now 52 mm (increased from 42 mm at diagnosis). What intervention is indicated?

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Correct answer: E — TEVAR is indicated — complicated chronic type B dissection with aortic expansion (>5 mm growth) despite medical therapy is an indication for endovascular repair; the INSTEAD-XL trial showed improved 5-year outcomes with pre-emptive TEVAR for uncomplicated type B dissection with aortic remodelling failure

Chronic type B aortic dissection management per the ESC 2024 Aortic Disease Guidelines: (1) optimal medical therapy continues lifelong (beta-blocker, BP control); (2) serial CT surveillance (3-6 monthly initially, then annually); (3) intervention (TEVAR) is indicated for: (a) aortic expansion >5 mm/6 months; (b) maximum diameter ≥55-60 mm; (c) malperfusion developing; (d) persistent patent false lumen with progressive dilatation (as in this patient — 42→52 mm in 6 months); (4) the INSTEAD-XL trial showed that pre-emptive TEVAR in uncomplicated chronic type B dissection improved 5-year aorta-specific survival (promoting false lumen thrombosis and favourable aortic remodelling). This patient's 10 mm growth in 6 months is well above the acceptable threshold, and the patent false lumen drives ongoing aortic expansion. TEVAR covers the primary entry tear, promoting false lumen thrombosis.

Reference: ESC (2024): Aortic Disease; INSTEAD-XL Trial