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Endovascular Repair vs. Medical Treatment in Type B Aortic Dissection
Quick Takes
- This retrospective study evaluated early and mid-term outcomes in patients with acute uncomplicated type B aortic dissection (TBAD) undergoing thoracic endovascular aortic repair (TEVAR) versus best medical treatment (BMT).
- In the early stage (30 days or less), TEVAR was associated with more complications than BMT. However, TEVAR had a decreased risk of late death and late aortic rupture when compared to BMT at 5 years.
- TEVAR should be considered first-line treatment to improve the late outcomes in patients with acute uncomplicated thoracic TBAD.
Study Questions:
In patients with acute uncomplicated type B aortic dissection (TBAD), what are the early and mid-term outcomes in patients undergoing thoracic endovascular aortic repair (TEVAR) versus best medical treatment (BMT)?
Methods:
Consecutive patients with acute, uncomplicated TBAD between 2008 and 2018 at a Huazhong University hospital were retrospectively reviewed. Patients ages <18 years were excluded, as well as those with Marfan or Ehlers-Danlos syndrome, dissection secondary to trauma, iatrogenic injury, or intramural hematoma. Patients were divided into two groups: those who were treated with TEVAR in addition to BMT (blood pressure control [<140/90 mm Hg] and close follow-up), and those who received BMT alone. Early adverse events were defined as any complication associated with the dissection occurring in-hospital or 30 days after diagnosis and included acute renal failure, type 1 endoleak, stroke, rupture, retrograde type A aortic dissection, and organ failure. Late adverse events were defined as those which occurred more than 30 days after diagnosis.
Results:
A total of 357 patients were retrospectively analyzed: 191 patients underwent TEVAR, and 166 received BMT. After propensity-score matching, 145 matched pairs were generated with no statistically significant differences in baseline variables. In this matched population, 30-day mortality was not statistically different between TEVAR and BMT groups (0.7 vs. 2.1%, p = 0.622), although a significantly larger number of early adverse events were observed in patients who underwent endovascular repair (p = 0.003). In contrast, survival at 5 years was greater in the TEVAR group (91.9 vs. 82.2%, p = 0.028), as was freedom from aortic-related mortality (94.1 vs. 86.1%, p = 0.044). The cumulative incidence of rupture at 5 years was greater in the BMT group (13.7%) versus the TEVAR group (5.1%) (p = 0.024).
Conclusions:
In patients with acute uncomplicated TBAD, TEVAR was associated with a decreased risk of late death and late aortic rupture compared to BMT. TEVAR did have more complications in the early stage (first 30 days), although these were mostly mild and transient.
Perspective:
There has been a long-standing consensus to treat TBAD medically. However, long-term outcomes have remained poor, with >75% of patients suffering from post-dissection aneurysms requiring further surgical treatment. Since its inception in 1994, TEVAR has become an effective alternative to surgery in patients with acute complicated TBAD. However, its role for acute uncomplicated TBAD remains unclear. This retrospective study nicely evaluated both the short-term and mid-term risks in both patients undergoing TEVAR and medical therapy only. Type 1 endoleak was the most common complication in the TEVAR group (6.9%), although this resolved in several patients on follow-up computed tomography angiography imaging and did not continue to be a permanent complication. In the BMT group, the most common complication was aortic rupture (9.7%). While this retrospective study obviously has potential selection bias and confounding variables even after propensity matching, it suggests the need for further prospective randomized trials.
Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Prevention, Vascular Medicine, Aortic Surgery, Cardiac Surgery and Arrhythmias, Interventions and Vascular Medicine
Keywords: Acute Kidney Injury, Aneurysm, Dissecting, Aorta, Thoracic, Aortic Rupture, Biometry, Blood Pressure, Cardiac Surgical Procedures, Dissection, Endoleak, Endovascular Procedures, Secondary Prevention, Stroke, Vascular Diseases
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