Predictors of Late Intervention for Type B Aortic Dissection
What clinical and anatomic factors are associated with the need for subsequent aortic intervention in patients who present with uncomplicated type B aortic dissection (TBAD)?
A single-center registry was queried from 2000 to December 2013 for patients presenting with acute uncomplicated TBAD initially managed medically. Predictors of aortic intervention among those with follow-up cross-sectional imaging were determined using Cox regression analyses.
Mean follow-up was 6.8 years (range, 0.1-13.6 years). 97/254 (38%) patients required an aortic intervention during follow-up; 30 (12%) patients required an early intervention (defined as <180 days after presentation), and 67 (26%) were treated during late follow-up (100% for aneurysmal degeneration). Predictors of late aortic intervention included entry tear >10 mm (odds ratio [OR], 2.1; 95% confidence interval [CI], 1.5-3.8; p = 0.03), total aortic diameter >40 mm at time of presentation (OR, 2.2; 95% CI, 1.8-4.3; p = 0.02), false lumen diameter >20 mm (OR, 1.8; 95% CI, 1.3-4.7; p = 0.03), and increase in total aortic diameter >5 mm between serial imaging studies (OR, 2.3; 95% CI, 1.3-3.5; p = 0.02). Complete thrombosis of the false lumen was protective against late intervention (OR, 0.22; 95% CI, 0.11-0.48; p < 0.01).
Nearly 40% of patients who present with an uncomplicated TBAD ultimately required an aortic intervention. All of the late interventions were performed for aneurysmal degeneration.
Decision making in patients presenting with uncomplicated TBAD remains an inexact science. This series contributes additional information regarding the likelihood of subsequent need for thoracic endovascular aortic repair (TEVAR), including associated risk factors and related indications. The majority of TEVARs were performed late (defined as 180 days or more) after initial diagnosis. These results suggest that decisions regarding TEVAR can be safely deferred until after the acute presentation for most patients. The authors’ conclusion suggests that these results can be used to guide the desirability of early TEVAR, but caution is warranted when considering more aggressive approaches in stable patients given the 5%-15% 30-day mortality associated with TEVAR quoted in this manuscript, as well as the fact that medical management was definitive more often than not. The single-center study design may have resulted in conservative estimates of both mortality and subsequent interventions if they occurred at another center (and therefore may have been missed), and it is worthwhile to note that roughly 14% of patients in the initial cohort were excluded due to lack of any follow-up imaging. An advantage of this study, however, is the availability of detailed information regarding the indications for TEVAR (increased diameter was the most common, followed by visceral and then extremity ischemia; none ruptured). Prospective assessment of the predictors of late intervention as criteria for early intervention will be needed to determine whether pre-emptive TEVAR is appropriate for select patients, and the identified risk factors may be useful in the meantime for clinicians struggling between intervention and observation.
Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Vascular Medicine, Aortic Surgery, Interventions and Imaging, Interventions and Vascular Medicine
Keywords: Aneurysm, Dissecting, Aortic Aneurysm, Thoracic, Cardiac Surgical Procedures, Cardiology Interventions, Diagnostic Imaging, Early Medical Intervention, Endovascular Procedures, Risk Factors, Thrombosis, Vascular Diseases
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