Abstract Body: Introduction
Transcatheter aortic valve replacement (TAVR) is the standard of care for symptomatic severe aortic stenosis (AS) in high-risk surgical candidates. Although generally safe, aortic dissection (AD) is a rare but serious complication, occurring in 0.6% to 1.9% of cases post-TAVR. Type B aortic dissection (TBAD), affecting the descending thoracic aorta distal to the left subclavian artery, is even rarer. Variability in symptoms, acuity, and extent of TBAD complicates management, especially given the lack of established guidelines. Here, we present a challenging case of TBAD following TAVR.
Case Presentation
A 75-year-old woman reported mild abdominal pain the night after an elective TAVR. Without other concerning findings, she was discharged with proton pump inhibitors and analgesics. One week later, she returned with persistent abdominal pain radiating to the back. Computed tomography angiography (CTA) revealed a TBAD with an intramural hematoma distal to the left subclavian artery.
Anti-impulse therapy was initiated with esmolol to maintain a heart rate below 60 bpm and nicardipine to achieve a systolic blood pressure under 120 mmHg. However, her symptoms and blood pressure remained uncontrolled, necessitating surgical intervention.
Intraoperative ultrasound identified antegrade propagation of the dissection, a finding not evident on preoperative CTA. The patient underwent left carotid-to-left subclavian artery bypass using a Dacron graft, thoracic endovascular aortic repair (TEVAR) spanning zones 3 to 5 under intravascular ultrasound guidance, and proximal subclavian artery coil embolization via left radial access. She recovered uneventfully and was discharged home with physiotherapy.
Discussion
TBAD carries an in-hospital mortality rate of 13%. AHA/ACC guidelines recommend medical management as first line therapy, though the 30-day mortality for medically treated TBAD remains 10%. Trials like ADSORB and INSTEAD-XL suggest that TEVAR alongside medical therapy improves outcomes, but long-term data are lacking, particularly on the optimal timing of TEVAR.
This case highlights the importance of clinical vigilance for TBAD, which can present sub-acutely after TAVR. A tailored multimodal approach incorporating medical and endovascular management is critical for successful outcomes. Further research is needed to establish standardized protocols for managing TBAD in this unique population.