Endovascular Repair of Type B Acute Aortic Dissection
What are the long-term outcomes associated with thoracic endovascular aortic repair (TEVAR) compared to medical management among patients with uncomplicated acute type B aortic dissection?
A cohort of 338 patients with uncomplicated acute type B aortic dissection treated between 2003 and 2014 at three tertiary medical centers were retrospectively identified. Medical records were reviewed; retrieved images were reviewed, including computed tomography angiography, to assess false lumen thrombosis and the extent of dissection. Early and late outcomes were analyzed. Aorta-related adverse events were defined as rupture, aortic enlargement >60 mm, retrograde type A dissection, ulcer-like projection, endoleak, or stent graft-induced new entry.
TEVAR procedures (193 stent grafts) were performed among 184 patients, and medical treatment among 154 patients. Early adverse events and 30-day mortality were not significantly different between groups (1 of 184 [0.5%] in the TEVAR group, 4 of 154 [2.6%] in the medical group, p = 0.18). Patients treated medically had significantly higher aorta-related adverse events compared with patients treated with TEVAR (p = 0.025, roughly 38% vs. roughly 28% at approximately 5 years). All-cause mortality with TEVAR was significantly lower than that associated with medical therapy (p = 0.01, roughly 11% vs. roughly 14% at approximately 5 years).
The authors concluded that TEVAR is feasible treatment in the acute setting among patients with uncomplicated type B aortic dissection, with fewer aortic-related adverse events and lower mortality rate compared to medical therapy.
Patients with complicated acute type B aortic dissection treated with TEVAR have better early survival compared to patients treated with open surgical repair. However, many patients with uncomplicated acute type B aortic dissection are treated conservatively, without intervention. TEVAR also has been used among patients with uncomplicated type B dissection, based on the belief that thrombosis of the false lumen is associated with better clinical outcomes. Previously published studies have been inconsistent in demonstrating improved outcomes associated with TEVAR in uncomplicated type B dissection. This retrospective study adds weight to the argument to use TEVAR rather than conservative medical treatment. However, note should be made of some trends toward differences between patients in the two treatment groups in this ‘all-comers’ retrospective review; and broad standard deviations around means at least raise some questions as to the statistical methodologies employed.
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