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Aortic Remodeling, Volumetric Analysis, and Clinical Outcomes of Endoluminal Exclusion of Acute Complicated Type B Thoracic Aortic Dissections
Study Questions:
What are the long-term outcomes associated with thoracic endovascular aortic repair (TEVAR) of acute complicated type B dissections (ABAD)?
Methods:
From 2002 to 2009, 41 consecutive patients with ABAD were treated with TEVAR in a single center Food and Drug Administration (FDA)-approved investigational device exemption (IDE) trial. Indications for TEVAR were malperfusion (17), rupture (12), impending rupture (5), and intractable pain (6) and uncontrolled hypertension (1). A total of 52 procedures were performed (40 primary, 12 secondary). Two patients required greater than 2 interventions. Postoperatively, 3-D computed tomography reconstructions were analyzed for changes in aortic volume, and false and true lumen expansion.
Results:
Average patient age was 67.6 years. Mean follow-up was 12.4 months (range, 0-60 months); 32 of the 41 patients (78%) had American Society of Anesthesiologists (ASA) scores ≥4. Of the 40 primary interventions, 42% were emergent. Successful endograft deployment was achieved in all 40 primary interventions and in 11 of 12 secondary interventions. The single failure was significant, resulting in a lethal cardiac tamponade. The 30-day mortality rate for primary interventions was 4.9% for malperfusion, 4.9% for rupture, and 0% for all others. Late mortality (>30 days) was 0% for mild malperfusion, 9.8% for rupture, and 2.4% for all others. Overall mortality was 4.9%, 14.7%, and 2.4%, respectively. Permanent stroke and paraplegia rates were 4.9% and 0%, respectively. 26.9% of patients died during the 5-year follow-up. Of the 33 patients without endoleaks, true lumen volume increased by 29% at 1 month, 51% at 1 year, and 80% at 5 years. False lumen volume regression was 69%, 76%, and 86%, respectively. True lumen volume did not change in the endoleak group, but increased 50% at 2 years after secondary intervention.
Conclusions:
The authors concluded that TEVAR offers a potential solution to treatment of patients with ABAD. In the absence of endoleaks or distal reperfusion, TEVAR leads to favorable remodeling of the aorta extending out to 5 years.
Perspective:
Management of ABAD is complicated and associated with significant morbidity and mortality. The outcomes reported here (despite 78% of the patients being ASA classification ≥4) are impressive, but not as much as the 0% paraplegia rate despite extensive coverage of the thoracic aorta and lack of spinal cord protection. As with all endovascular or surgical procedures, the key to good outcomes remains proper patient selection. Patients with distal aortic reperfusion and endoleaks did not fare as well as their counterparts without any leaks. Methods to identify patients at risk for endoleaks after TEVAR for ABAD should be a priority.
Keywords: Blood Vessel Prosthesis Implantation, Stroke, Aortic Aneurysm, Thoracic, Follow-Up Studies, Tomography, X-Ray Computed, Pain, Intractable, Postoperative Period, Endoleak, Spinal Cord, Paraplegia, Aortic Aneurysm, Abdominal, Hypertension, United States, Cardiac Tamponade
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