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Abdominal Aortic Dissection: A Shift to Endovascular Treatment Is Probably Justified

In this issue of the JEVT, Jawadi et al. reported their single tertiary center experience in treating isolated abdominal aortic dissection (AAD) by endovascular means. They retrospectively studied 21 patients during a 12-year period, achieving excellent results, with null 30-day mortality or major adverse events. During a mean follow-up period of nearly 6 years, all patients showed full aortic remodeling and a remarkable 95% freedom from reintervention. These results are in accordance with our recently published series of 14 patients with isolated spontaneous acute AAD treated endovascularly during an 8-year period. We reported no procedure-related deaths, while the freedom from reintervention at 60 months was 91%. For many years, AAD has been considered a quite rare clinical entity, with an estimated incidence of 1% to 4% of all aortic dissections. A review of the literature published in 2009 identified just 92 cases, while only 1.3% of the patients included in the International Registry of Acute Aortic Dissection (IRAD) presented with AAD. In their study, Jawadi et al. reported 27 patients with AAD in their observation period (21 treated endovascularly, one with open surgery, and 5 conservatively). This cohort represented nearly 11% of all aortic dissections encountered in their large referral center. Ours, too, is the only referral center in our territory, and we were surprised to find that in the 8-year period in which we treated our 14 acute AAD cases, we treated 24 patients for an acute type B thoracic dissection. Taking into account these two large and most recent series, it seems that AAD is not so rare a clinical entity as it was generally thought; perhaps it has been underdiagnosed in relation to thoracic aortic dissections. Indeed, the differential diagnosis of acute thoracic pain is mainly limited to a small group of diseases, and cardiologists usually maintain a high clinical suspicion for thoracic aortic dissection. Thus, they very often ask for thoracic computed tomography (CT) in the absence of a cardiac pathology, identifying most cases of acute thoracic dissection. On the contrary, AAD usually presents with diffuse abdominal and/or back pain, while malperfusion is rarely seen since the entry tear is usually below the renal arteries and the disease is localized just in the abdominal aorta. Given that many abdominal pathologies present in a similar way and doctors usually involved in the diagnosis of an acute abdomen may not be well aware of this manifestation of acute aortic syndrome, the correct diagnosis could have been missed in many cases. However, the liberal use of diagnostic CT in recent years across a broad range of presenting symptoms may have increased the identification of AAD.