Impact of timing on major complications after thoracic endovascular aortic repair for acute type B aortic dissection

A Systematic Review and Meta-Analysis of Current Evidence Related to the Impact of Endovascular Repair Timing on Prognosis of Acute Stanford Type B Aortic Dissection

BACKGROUND

The objective of this study was to determine whether thoracic endovascular aortic repair (TEVAR) timing is more beneficial in the acute phase (first 14 days) than in the subacute phase (14-90 days) for the administration of acute Stanford type B aortic dissection (TBAD).

METHODS

A comprehensive literature search was conducted in databases (EMBASE, PubMed and Cochrane Library) until December 2023 to identify studies reporting the results of TEVAR used for patients with acute TBAD. Odds ratios (ORs) with 95% confidence intervals (CIs) were estimated utilizing either the random-effects model or the fixed-effects model.

RESULTS

A total of 25 studies involving 4,827 individuals with TBAD (including 1,609 with subacute TBAD) met our selection criteria. Early results revealed a lower incidence of Ia endoleaks (OR, 1.55; 95% CI, 1.03-2.33; P = 0.04) and aortic ruptures (OR, 2.89; 95% CI, 0.98-8.50; P = 0.05) in subacute TBAD. Apart from these findings, there was little difference in other incidents between the 2 groups. Regarding late outcomes, we observed significantly higher rates of retrograde dissection (OR, 2.12; 95% CI, 1.04-4.34; P = 0.04), distal stent-induced new entry (OR, 2.39; 95% CI, 1.24-4.61; P = 0.009), and reintervention (OR, 1.45; 95% CI, 0.05-1.99; P = 0.02) in acute TBAD than in subacute TBAD, whereas no significant differences were found for other outcomes between the 2 groups. Also, TEVAR appeared to yield comparable results for false lumen thrombosis and true lumen regression in both groups.

CONCLUSIONS

Subacute TBAD repair with TEVAR demonstrates a more effective reduction in adverse event rates compared to immediate treatment in the acute phase.

Incidence, Predictors, and Implications of Secondary Aortic Intervention Following Thoracic Endovascular Aortic Repair for Type B Dissection

BACKGROUND

Secondary aortic intervention (SAI) following thoracic endovascular aortic repair (TEVAR) is not uncommon. However, a satisfactory management system has not been established for these patients. We aimed to report our single-center experience with SAI after prior TEVAR for type B aortic dissection (TBAD).

METHODS

From January 2010 to May 2017, 860 eligible patients with TBAD underwent TEVAR. One hundred seven (12.4%) patients required SAI, either endovascularly (n=76) or surgically (n=31). The main indications for SAI were entry flow (n=58 [54.2%]), aneurysm expansion of the proximal or remote aorta (n=26 [24.3%]), retrograde type A aortic dissection (n=11 [10.3%]), distal stent-graft-induced new entry tear (n=6 [5.6%]), and stent migration (n=4 [3.7%]). The Kaplan-Meier curves were generated to determine the degree of freedom from SAI and the prognosis. Cox proportional hazards were used to screen for risk factors for SAI and poor prognosis.

RESULTS

The overall 30-day mortality rate after SAI was 4.7% (n=5): endovascular (n=2 [2.6%]) vs open surgery (n=3 [9.7%]; p=0.145). The cumulative survival rates with or without SAI were 86.3%±3.6% vs 95.7%±0.8% at 3 years and 82.0%±4.2% vs 92.2%±1.1% at 5 years, respectively (log-rank p<0.001). Although no significant difference in survival was observed, the incidence of SAI was significantly greater in patients who underwent TEVAR during the chronic phase (acute [11.6%] vs subacute [9.6%] vs chronic [27.8]; p<0.001). Multivariate regression analysis revealed that prior TEVAR in the chronic phase (hazard ratio [HR]=1.73, 95% confidence interval [CI]=1.03-2.90; p=0.039), maximum aortic diameter (HR=1.05, 95% CI=1.04-1.07; p<0.001), and arch involvement (HR=1.48, 95% CI=1.01-2.18; p=0.048) were predictors of the incidence of SAI. In addition, the maximum aortic diameter was demonstrated to be the only risk factor for prognosis after adjusting for confounding factors.

CONCLUSIONS

Thoracic endovascular aortic repair for chronic TBAD patients should be reconsidered. Open surgery is preferable for those with proximal progression, whereas endovascular treatment is more suitable for distal lesions. Close surveillance and timely reintervention after TEVAR, whether via endovascular techniques or open surgery, are necessary to prevent devastating complications.

CLINICAL IMPACT

The management of patients with type B aortic dissection (TBAD) after thoracic endovascular aortic repair (TEVAR) is challenging. We summarized our single-center experience regarding secondary aortic intervention after TEVAR for TBAD. We found that TEVAR for chronic TBAD patients should be carefully evaulated, and open surgery is recommended for those with proximal progession, while endovascular treatment is more preferable for distal lesions.

Optimal Timing of Pre-emptive Thoracic Endovascular Aortic Repair in Uncomplicated Type B Aortic Dissection: A Network Meta-Analysis

BACKGROUND

This network meta-analysis compares outcomes of optimal medical therapy (OMT) and pre-emptive thoracic endovascular aortic repair (TEVAR) for uncomplicated type B aortic dissection at different phases of chronicity.

METHODS

MEDLINE and EMBASE were searched through November 2023. Pooled short-term outcomes (short-term mortality, perioperative complications) and long-term outcomes (all-cause mortality, aortic-related mortality, aortic re-intervention rates) were calculated.

RESULTS

Systematic review identified 17 studies (2 randomized controlled trials, 3 propensity score matching, and 2 inverse probability weighting). Subacute-phase intervention had lower short-term mortality than the acute-phase (hazard ratio [HR] [95% confidence interval [CI]]=0.60 [0.38-0.94], p=0.027). No significant differences were observed in aortic rupture and paraplegia. Acute-phase TEVAR had a higher stroke incidence than subacute-phase intervention (HR [95% CI]=2.63 [1.36-5.09], p=0.042), chronic (HR [95% CI]=2.5 [1.03-6.2], p=0.043), and OMT (HR [95% CI]=1.57 [1.12-2.18], p=0.008). Acute-phase TEVAR had higher long-term all-cause mortality than subacute-phase intervention (HR [95% CI]=1.34 [1.03-1.74], p=0.03). Optimal medical therapy had elevated long-term all-cause mortality compared with subacute-phase TEVAR (HR [95% CI]=1.67 [1.25-2.33], p<0.001) and increased long-term aortic-related mortality vs acute-phase (HR [95% CI]=2.08 [1.31-3.31], p=0.002) and subacute-phase (HR [95% CI]=2.6 [1.62-4.18], p<0.01) interventions. No significant differences were observed in aortic re-intervention rates.

CONCLUSIONS

Pre-emptive TEVAR may offer lower all-cause mortality and aortic-related mortality than OMT. Considering lower short-term mortality, perioperative stroke rate, and long-term mortality, our findings support pre-emptive TEVAR during the subacute phase.

CLINICAL IMPACT

The optimal timing of pre-emptive thoracic endovascular aortic repair (TEVAR) for uncomplicated type B aortic dissection remains uncertain. This network meta-analysis suggests that the subacute phase (14-90 days from symptom onset) emerges as the optimal timing for pre-emptive TEVAR. This window is associated with lower rates of short-term complications and higher long-term survival rates compared with alternative strategies.

Predicting adverse events after thoracic endovascular aortic repair for patients with type B aortic dissection

The potential of adverse events (AEs) after thoracic endovascular aortic repair (TEVAR) in patients with type B aortic dissection (TBAD) has been reported. To avoid the occurrence of AEs, it is important to recognize high-risk population for prevention in advance. The data of 261 patients with TBAD who received TEVAR between June 2017 and June 2021 at our medical center were retrospectively reviewed. After the implementation of exclusion criteria, 172 patients were finally included, and after 2.8 years (range from 1 day to 5.8 years) of follow up, they were divided into AEs (n = 41) and non-AEs (n = 131) groups. We identified the predictors of AEs, and a prediction model was constructed to calculate the specific risk of postoperative AEs at 1, 2, and 3 years, and to stratify patients into high-risk (n = 78) and low-risk (n = 94) group. The prediction model included seven predictors: Age > 75 years, Lower extremity malperfusion (LEM), NT-proBNP > 330 pg/ml, None distal tear, the ratio between the diameter of the ascending aorta and descending aorta (A/D ratio) > 1.2, the ratio of the area of the false lumen to the total aorta (FL ratio) > 64%, and acute TEVAR, which exhibited excellent predictive accuracy performance and discriminatory ability with C statistic of 82.3% (95% CI 77.3-89.2%). The prediction model was contributed to identify high-risk patients of postoperative AEs, which may serve to achievement of personalized treatment and follow-up plans for patients.

Current perspectives in acute type B aortic dissections: a literature review

In this new millennial, endovascular strategies have revolutionized the treatment of acute type B aortic dissection (aTBAD). With reduced in-hospital mortality and good long-term outcomes TEVAR has become the gold standard for the treatment of complicated dissection and is gaining increasing support for its preventive applicability in some uncomplicated dissections. With this new paradigm came a shift of the treatment goal where just covering the entry tear is not enough and instead achieving long-term positive thoracoabdominal remodeling is needed. More extensive approaches with composite device designs (covered stent graft and bare metal stent) emerged to answer this aortic conundrum. At 5-year of follow-up, "Provisional ExTension To Induce COmplete Attachment technique" (PETTICOAT) and its evolution "Stent assisted balloon induced intimal disruption and relamination in aortic dissection repair" (STABILISE) seem to be safe techniques that can allow, when anatomically feasible, excellent aortic remodeling and, in some cases, even the healing of the dissection. Nevertheless, STABILISE results, although promising, are mostly based on small series and therefore need to be validated by analyzing medium-long-term results from the international registry. Given the plethora of new data and the disparity of expert opinions on the best treatment to adopt, in this review we aim to summarize the current knowledge on the results of these different strategies for acute TBAD.

Timing of Intervention and Long-Term Outcomes of Type B Aortic Intramural Hematoma with Intimal Disruption at Admission

BACKGROUND

To compare the 30-day and long-term outcomes between patients with concomitant type B intramural hematoma and intimal disruption upon admission who underwent endovascular repair in the acute or subacute phases.

METHODS

Data were extracted from January 1, 2010, to December 31, 2019. Logistic regression and Cox regression were performed to evaluate the impact of timing of intervention on 30-day and long-term outcomes, respectively.

RESULTS

The study included 241 patients, among which 159 were in the acute group. No significant difference was observed in 30-day mortality (0.6% vs. 0%, P = 1), 30-day complication rate (2.5% vs. 1.2%, P = 0.664), long-term all-cause mortality (10.7% vs. 7.3%, P = 0.540), and aortic reintervention rate (2.5% vs. 2.4%, P = 1) between the acute and subacute group. In multivariable analysis, the timing of intervention was not associated with 30-day mortality (odds ratio (OR) = 0, 95% confidence interval CI: 0-Inf, P = 0.999), 30-day complication (OR = 0.30, 95% CI: 0.02-3.77, P = 0.348), long-term mortality (hazard ratio = 0.56, 95% CI: 0.20-1.61, P = 0.283), and aortic reintervention (OR = 0.97, 95% CI: 0.15-6.08, P = 0.970).

CONCLUSIONS

For patients with concomitant type B intramural hematoma and intimal disruption upon admission, there is no significant difference in 30-day and long-term outcomes between those who undergo endovascular treatment in the acute or subacute phase.

The Role of Endovascular Repair Timing in Uncomplicated Acute Type B Intramural Hematoma Management

BACKGROUND

With favorable results of thoracic endovascular aortic repair (TEVAR) in patients with uncomplicated acute type B intramural hematoma (uTBIMH), TEVAR is increasingly utilized in the management of patients with uTBIMH. However, optimal timing for intervention has not been decided. This study aimed to compare the efficacy of acute and delayed TEVAR in patients with uTBIMH.

METHODS

We included patients with uTBIMH who underwent TEVAR between October 2014 and December 2021. The participants were divided into the acute TEVAR (aTEVAR) and delayed TEVAR (dTEVAR) groups. We analyzed the total aortic diameter (TAD)/true lumen diameter (TLD) ratio on computed tomography angiography (CTA) and aortic-related adverse events and all-cause mortality (AREM).

RESULTS

We included 34 individuals with uTBIMH, among which 20 underwent aTEVAR and 14 underwent dTEVAR. We observed no significant differences in baseline characteristics between both groups. However, compared with the aTEVAR group, better aortic remodeling was achieved in the dTEVAR group before discharge (1.32 ± 0.11 vs. 1.21 ± 0.09, P = 0.005) and at the 1-year follow-up (1.18 ± 0.09 vs. 1.10 ± 0.04, P = 0.034). Although the 30-day and 1-year follow-up outcomes of AREM were not significantly different, the Kaplan-Meier analysis showed that AREM incidence in the dTEVAR group was significantly lower than that in the aTEVAR group (85.7% for dTEVAR vs. 65.0% for aTEVAR, log-rank P = 0.20). Moreover, subgroup analysis revealed a significant difference in the TAD/TLD ratio between the aTEVAR and dTEVAR groups in individuals without a focal intimal disruption (1.33 ± 0.11 vs. 1.17 ± 0.09, P = 0.008).

CONCLUSIONS

For individuals with uTBIMH, delaying TEVAR by >7 days improved aortic remodeling and lowered the incidence of early AREM. Additionally, the absence of focal intimal disruption on preoperative CTA supports delayed intervention.

Thoracic endovascular aortic repair for hyperacute, acute, subacute and chronic type B aortic dissection: Meta-analysis of reconstructed time-to-event data

Since the optimal timing for thoracic endovascular aortic repair (TEVAR) in the context of type B aortic dissections (TBAD) remains an open question, we performed a systematic review with meta-analysis to evaluate outcomes of TEVAR according to the phases of TBAD - hyperacute, acute, subacute and chronic. We carried out a pooled meta-analysis of time-to-event data extracted from studies published by June 2023 for the following outcomes: all-cause mortality, aortic-related mortality, and late aortic reinterventions. Thirteen studies met our eligibility criteria, comprising 4,793 patients (10.3 % hyperacute, 51.9 % acute, 25.9 % subacute, 11.9 % chronic). Considering the overall population, we observed a statistically significant difference between the groups (Log-rank test, P < 0.0001) and the main differences were found in the following comparisons: hyperacute versus acute (HR 1.61; 95 %CI 1.21-2.13; P = 0.001); hyperacute versus chronic (HR 1.70; 95 %CI 1.17-2.46; P = 0.005); subacute versus acute (HR 0.78; 95 %CI 0.63-0.98; P = 0.032). Considering the population with uncomplicated TBAD, we also observed a statistically significant difference for all-cause death between the groups (Log-rank test, P < 0.0001) and the main differences were found in the comparisons for subacute versus acute (HR 0.72; 95 %CI 0.58-0.88; P = 0.002). Furthermore, we observed statistically significant differences between the groups for aortic-related death (Log-rank test, P < 0.0001) and late aortic reintervention (Log-rank test, P < 0.0001), all favoring mostly the subacute phase as the optimal timing for TEVAR. In conclusion, there seems to be a timing-specific difference in the outcomes of TEVAR for TBAD pointing to the subacute phase as the optimal timing to achieve better long-term outcomes.

Endovascular repair of acute vs. subacute uncomplicated type B aortic dissection: a systematic review and meta-analysis

Objective

This study aimed to conduct a meta-analysis evaluating the optimal timing for endovascular repair of acute versus subacute uncomplicated Type B Aortic Dissection.

Method

PubMed, EMBASE, web of science and Cochrane Library was interrogated to identify Electronic bibliographic studies updated to January 2023 to collect studies compared the clinical outcomes of endovascular repair for Acute Versus Subacute Uncomplicated Type B Aortic Dissection. Data were aggregated as pooled odds ratios (OR) using the fixed or random effects models according to the significance of heterogeneity, Pooled odds ratios (OR) were calculated by RevMan 5.3 and applied with fixed or random-effect models.

Result

A comprehensive literature search found 322 citations published and finally among them 6 studies containing 3,769 patients (acute group 2,642, subacute group 1,127) were included in review. There is an increased risk of 30-day complications (OR = 1.51,95%CI,1.26-1.81) 30-day mortality (OR = 2.39,95%CI, 1.55-3.67) and 1-year mortality (OR = 1.71,95%CI,1.27-2.30) for an acute uTBAD group compared to subacute ones. Similarly, reintervention was more likely in the acute group than in the subacute group (OR = 1.42,95%CI,1.05-1.91). However, no significant differences were found in long-term mortality.

Conclusion

This meta-analysis confirmed that there was no significant difference in the long-term prognosis between the acute and subacute phases in the timing of surgery. However, considering the high incidence of complications, high re-intervention rate and one-year mortality probably caused by high intima fragility in the acute phase, endovascular repair at subacute phase appears to favorably compare with acute strategy. But future studies with adequate patient numbers and longer-term follow-up are necessary to further verify the study conclusion.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021247609, identifier PROSPERO CRD42021247609.

Editor's Choice - Optimal Timing of Thoracic Endovascular Aortic Repair for Uncomplicated Type B Aortic Dissection: A Systematic Review and Meta-Analysis

OBJECTIVE

Type B aortic dissections (TBAD) have a high mortality rate and are challenging to both classify and manage. There is significant evidence supporting the use of early intervention in complicated TBAD with thoracic endovascular aortic repair (TEVAR). Currently, there is equipoise regarding the optimal timing for TEVAR in TBAD. This systematic review answers whether early TEVAR in the hyperacute or acute phase of the disease has improved aorta related events in the one year follow up period with no change in mortality rate when compared with TEVAR in the subacute or chronic phase.

DATA SOURCES

A systematic review and meta-analysis was performed with Preferred Reporting Items for Systematic Reviews and Meta-Analyses literature search guidelines for MEDLINE, Embase, and Cochrane Reviews until 12 April 2021. Inclusion and exclusion criteria targeting the review objective and high quality research were employed by separate authors.

REVIEW METHODS

These studies were then reviewed for suitability, risk of bias, and heterogeneity using the ROBINS-I tool. Results were extracted for the meta-analysis with RevMan using odds ratios with 95% confidence intervals with I2 used to assess heterogeneity.

RESULTS

Twenty articles were included. A meta-analysis showed no significant difference between acute phase TEVAR (excluding the hyperacute phase) and subacute or chronic phase TEVAR for the all cause 30 day and one year mortality rates. Aorta related events in the 30 day post-operative period were unaffected by the timing of intervention but had significant improvement in aorta related events in the one year follow up favouring TEVAR in the acute phase compared with subacute or chronic phase. Risk of confounding was high but with low heterogeneity.

CONCLUSION

Without prospective randomised controlled studies, it is evident that there is improved aortic remodelling in long term follow up with intervention in the acute setting from three to 14 days after symptom onset. This suggests that TEVAR in the acute period of TBAD is both safe and beneficial, and can be considered for early stent grafting based on clinical, anatomical and patient factors.

A systematic review and meta-analysis of retrograde type A aortic dissection after thoracic endovascular aortic repair in patients with type B aortic dissection

BACKGROUND

Retrograde type A dissection (RTAD) is a devastating complication of thoracic endovascular repair (TEVAR) with low incidence but high mortality. The objective of this study is to report the incidence, mortality, potential risk factors, clinical manifestation and diagnostic modalities, and medical and surgical treatments.

METHODS

A systematic review and single-arm and two-arm meta-analyses evaluated all published reports of RTAD post-TEVAR through January 2021. All study types were included, except study protocols and animal studies, without time restrictions. Outcomes of interest were procedural data (implanted stent-grafts type, and proximal stent-graft oversizing), the incidence of RTAD, associated mortality rate, clinical manifestations, diagnostic workouts and therapeutic management.

RESULTS

RTAD occurred in 285 out of 10,600 patients: an estimated RTAD incidence of 2.3% (95% CI: 1.9-2.8); incidence of early RTAD was approximately 1.8 times higher than late. Wilcoxon signed-rank testing showed that the proportion of RTAD patients with acute type B aortic dissection (TBAD) was significantly higher than those with chronic TBAD (P = .008). Pooled meta-analysis showed that the incidence of RTAD with proximal bare stent TEVAR was 2.1-fold higher than with non-bare stents: risk ratio was 1.55 (95% CI: 0.87-2.75; P = .13). Single arm meta-analysis estimated a mortality rate of 42.2% (95% CI: 32.5-51.8), with an I2 heterogeneity of 70.11% (P < .001).

CONCLUSION

RTAD is rare after TEVAR but with high mortality, especially in the first month post-TEVAR with acute TBAD patients at greater risk as well as those treated with proximal bare stent endografts.

Efficacy of endovascular repair in the treatment of retrograde ascending aortic intramural haematoma

BACKGROUND

The current treatment for retrograde ascending aortic intramural hematoma (RAIMH) remains challenging. This study aims to summarize the short-term results of endovascular repair in the treatment of retrograde ascending aortic intramural hematoma.

METHODS

Between June 2019 and June 2021, 21 patients (16 males and 5 females) with a retrograde ascending aortic intramural hematoma, aged 53 ± 14years, received an endovascular repair in our hospital. All cases involved an ascending aortic or aortic arch intramural hematoma. 15 patients had an ulcer on the descending aorta combined with an intramural hematoma in the ascending aorta and 6 patients had typical dissection changes on the descending aorta combined with an intramural hematoma in the ascending aorta. All patients had a successful endovascular stent-graft repair, with 10 cases operated on in the acute phase (<14 days) and 11 cases in the chronic phase (14-35 days).

RESULTS

A single-branched aortic stent graft system was implanted in 10 cases, a straight stent in 2 cases, and a fenestrated stent in 9 cases. All surgeries were technically successful. One of the patients developed a new rupture 2 weeks after surgery and was converted to a total arch replacement. No perioperative stroke, paraplegia, stent fracture or displacement, limb or abdominal organ ischemia occurred. The intramural hematomas started being absorbed on CT angiography images before discharge. There was no incidence of postoperative 30-day mortality, and the intramural hematomas in the ascending aorta and aortic arch were fully or partly absorbed.

CONCLUSION

Endovascular repair of retrograde ascending aortic intramural hematoma was shown to be safe and effective, and correlated with favorable short-term results.

Preemptive fenestrated endovascular repair aimed at perfusion of cervical branches in acute type B aortic dissection

OBJECTIVE

Most of the entry tears of uncomplicated type B aortic dissection are located in the distal arch and extends in a retrograde manner to the level of the left subclavian artery. Our objective was to evaluate feasibility and effectiveness using fenestrated sent graft with complete neck vessel preservation to treat uncomplicated type B aortic dissection.

SUBJECTS AND METHODS

We retrospectively reviewed the record of patients with uncomplicated type B aortic dissection who underwent fenestrated thoracic endovascular aortic repair in subacute phase (15-90 days) between August 2016 and April 2020. The Najuta fenestrated stent graft was placed proximally beyond he left subclavian artery (zone 0-2) in an attempt to seal the entry while preserving the neck vessels.

RESULTS

We evaluated 9 cases (male: 7, female: 2; median age 70 years). The median distance from the LSA to the proximal entry was 37 mm. The landing zones of the proximal end of the Najuta were zone 0: 3, zone 1: 2, and zone 2: 4 cases. Technical success was 100% with no 30-day death. None of the patients had a stroke, paraplegia or retrograde dissection, and no endoleak was observed. Complete aortic remodeling with false lumen resolution was obtained in all cases while each fenestrated vessels remained patent during the follow-up period.

CONCLUSION

Preemptive thoracic endovascular aortic repair aimed at perfusion of cervical branches using the Najuta fenestrated stent is safe and effective and may be considered as a reasonable treatment option for the treatment is a safe and an effective treatment.

Timing of Intervention for Aortic Intramural Hematoma

Intramural hematoma (IMH) is one of the acute aortic syndromes along with acute aortic dissection and penetrating aortic ulcer. The three conditions can occur alone or in combination with overlapping presentation. Medical, open surgical, and endovascular treatment is tailored depending on clinical presentation, timing, and location within the aorta. Among patients who present with acute IMH affecting the ascending aorta (Type A), urgent open surgical repair is considered the primary line of treatment in patients who are suitable candidates and unstable. The management of IMH in the descending aorta and aortic arch (Type B) is similar to that applied to treat acute dissections in the same segment. Medical treatment with sequential imaging is recommended in patients with uncomplicated course, and endovascular repair is indicated in patients with rupture, persistent pain, end-organ ischemia, or rapid aortic enlargement. This review discusses the ideal timing for treatment of IMH.

Acute or Subacute, the Optimal Timing for Uncomplicated Type B Aortic Dissection: A Systematic Review and Meta-Analysis

Objective

To evaluate the optimal timing (acute or subacute) of thoracic endovascular aortic repair (TEVAR) for uncomplicated B aortic dissection (uTBAD) through a systematic review and meta-analysis.

Method

A comprehensive literature search was undertaken across three major databases (EMBASE/Medline, PubMed, and Cochrane Library) and was assessed until November 2021 to identify studies reporting the outcomes of TEVAR utilized to treat patients with uTBAD. The continuous variables were compared between the two groups using t-test and the categorical variables were compared using the χ2-test. A meta-analysis was used to produce pooled odds ratios for early and follow-up outcomes. The random effects models were applied. A statistical analysis was performed using R software v.4.1.

Result

A comprehensive literature search found 490 citations published within the predetermined time span of the analysis. Three studies including 1,193 patients (acute group 718, subacute group 475) were finally included for downstream meta-analysis. An acute uTBAD group presented with higher rates both in 30-day complications (20.5 vs. 13.7%; p = 0.014) and mortality (4.6 vs. 1.3%; p = 0.004) than subacute group. The respiratory complications were significantly higher in the acute group than in the subacute group (10.8 vs. 5.0%; p = 0.015). The procedure success rate (90.8 vs. 93.6%; p = 0.329), the follow-up mortality (7.7 vs. 7.6%; p = 1) and dissection-related late mortality (3.9 vs. 5.3%; p = 0.603) showed no significant difference.

Conclusion

Our meta-analysis suggested that despite significantly higher 30-day complications and 30-day mortality in the acute uTBAD group, there was no significant difference in the follow-up mortality between the two groups.

Systematic Review Registration

PROSPERO, identifier: CRD42021247609.

What is the optimal timing for thoracic endovascular aortic repair in uncomplicated Type B aortic dissection?

BACKGROUND

Uncomplicated Stanford Type B aortic dissection (un-TBAD) is characterized by a tear in the aorta distal to the left subclavian artery without ascending aorta and arch involvement. Optimized cardiovascular control (blood pressure and heart rate) is the current gold standard treatment according to current international guidelines. However, emerging evidence indicates that thoracic endovascular aortic repair (TEVAR) is both safe and effective in the treatment of un-TBAD with improved long-term survival outcomes in combination with optimal medical therapy (OMT) relative to OMT alone. However, the optimal timeframe for intervention is not entirely clarified.

AIMS

This review critically addresses current state-of-the-art comparing TEVAR with OMT and corresponding clinical outcomes for un-TBAD based on timing of intervention.

METHODS

We carried out a comprehensive literature search on multiple electronic databases including PUBMED and Scopus to collate all research evidence on timing of TEVAR in uncomplicated Type B aortic dissection.

RESULTS

TEVAR has proven to be a safe and effective treatment for un-TBAD in combination with OMT through comparable survival outcomes, improved aortic remodeling, and relatively low periprocedural added risks. Though the timing of intervention remains controversial, it is becoming clear that performing TEVAR during the subacute phase of un-TBAD yields better outcomes compared to earlier and delayed (>90 days) intervention.

CONCLUSIONS

Further research is required into both short- and long-term outcomes of TEVAR in addition to its optimal therapeutic window for un-TBAD. With stronger evidence, TEVAR is likely to be adopted as the gold-standard intervention for un-TBAD with definitive timeframe guidelines.

Endovascular repair of acute type B thoracic aortic dissection

Approximately one-third of patients with acute Stanford type B or DeBakey type III aortic dissection (TBAD) will develop complications, including persistent symptoms, malperfusion, enlarging aneurysms and impending rupture. In these cases, TBAD becomes a surgical emergency that requires endovascular intervention to complement the medical therapy. The immediate goal of endovascular therapy is to reestablish flow to the true lumen, stabilize the aneurysm and prevent rupture. Long-term goals are the remodeling of the descending thoracic aorta and the prevention of further surgeries in the thoracoabdominal aorta. In this report, we describe our step-by-step endovascular approach to TBAD repair.

Timing of endovascular repair impacts long-term outcomes of uncomplicated acute type B aortic dissection

OBJECTIVE

To compare the 5-year outcomes of acute versus subacute thoracic endovascular aortic repair (TEVAR) in patients with uncomplicated acute type B aortic dissection (ATBAD).

METHODS

Between March 2008 and September 2018, 238 consecutive patients with uncomplicated ATBAD underwent TEVAR in the acute or subacute phase and were analyzed retrospectively. The primary end points were all-cause death and aortic-related death. The secondary end point was a composite of the outcomes of death from any cause, rupture, new dissection, retrograde type A aortic dissection, endoleak, and late reintervention. Inverse probability treatment weighting was used to balance baseline characteristics. Weight-adjusted Kaplan-Meier estimate with landmark analysis and weighted Cox model were performed to assess time-to-event outcomes.

RESULTS

In the inverse probability treatment weighting-adjusted population, the 30-day mortality was 1.5% in the acute TEVAR group and 0% in the subacute TEVAR group (P = .24). The incidence of 30-day adverse events occurred in 16.8% and 6.9% patients in the acute TEVAR and subacute TEVAR groups, respectively (P = .13). At 5 years, there was no statistically significant difference in all-cause death (hazard ratio [HR], 1.50; 95% confidence interval [CI], 0.59-3.81; P = .39) and aortic-related death (HR, 1.11; 95% CI, 0.34-3.60; P = .86) between the two groups. The composite outcomes occurred in 30 patients (23.0%) in the acute TEVAR group and 18 patients (22.3%) in the subacute TEVAR group, respectively (HR, 0.67; 95% CI, 0.36-1.25; P = .20). However, a landmark analysis of the composite outcomes indicated that there was a significant interaction between treatment effect and time (P_interaction = .01), with a significantly higher incidence of the composite outcomes in the acute TEVAR group compared with the subacute TEVAR group within 1 year (HR, 0.25; 95% CI, 0.08-0.79; P = .02), and a comparable rate between 1 and 5 years (HR, 1.25; 95% CI, 0.56-2.76; P = .59).

CONCLUSIONS

At the 5-year follow-up, no significant differences exist in the all-cause death and aortic-related death between acute and subacute TEVAR. However, acute TEVAR is associated with an increased rate of severe complications within 1 year, which suggests that performing TEVAR in the subacute phase of ATBAD may be the preferable option.

Endovascular therapies for Type B Aortic Dissection

Aortic dissection is a life-threatening condition resulting from a tear in the intimal layer of the aorta, requiring emergent diagnosis and prompt multi-disciplinary management strategy for best patient outcomes. While type A dissection involving ascending aorta is best managed surgically due to high early mortality, type B aortic dissection (TBAD) involving descending aorta generally has better outcomes with conservative management and medical therapy as primary strategy is favored. However, there has been a recent paradigm shift in management of TBAD due to late aneurysmal degeneration of TBAD increasing morbidity and mortality at longer-term. Late surgical intervention can be prevented by early endovascular intervention when combined with optimal medical therapy. In this narrative review, we explore available literature on different endovascular therapies for TBAD in different populations of patients.

IMPACT OF THORACIC ENDOVASCULAR AORTIC REPAIR TIMING ON AORTIC REMODELING IN ACUTE TYPE B AORTIC INTRAMURAL HEMATOMA

INTRODUCTION

Thoracic endovascular aortic repair (TEVAR) is increasingly utilized in the management of acute type B aortic intramural hematoma (TBIMH). Optimal timing for intervention has not been described. The aim of this study was to evaluate TEVAR timing on post-operative aortic remodeling.

METHODS

A retrospective chart review was performed on patients who underwent TEVAR for TBIMH from January 2008 to September 2018. Imaging was reviewed pre- and postoperatively. Primary data points included true lumen diameter (TLD) and total aortic diameter (TAD) at the site of maximal pathology. Primary endpoint was aortic remodeling evidenced by a TAD/TLD ratio closest to 1.0. Secondary outcome was occurrence of aortic-related adverse events and mortality (AREM): aortic rupture, aortic-related death, progression to dissection or need for aortic re-intervention within 12 months. Patients undergoing emergent TEVAR (within 24 hours, 'eTEVAR') were compared to the remainder - delayed TEVAR ('dTEVAR').

RESULTS

We analyzed 71 patients that underwent TEVAR FOR TBIMH; 25 underwent emergent TEVAR and 46 patients underwent dTEVAR (median: 5.5 days, range: 2-120 days). There were no differences in demographics and comorbidities and patients did not differ in presenting IMH thickness (12.6±3.1 mm vs. 11.3±4.1 mm, p=0.186) nor presenting TAD/TLD ratio (1.535±0.471 vs. 1.525±0.397, p=0.928) for eTEVAR and dTEVAR groups, respectively. eTEVAR patients had larger average presenting maximal descending aortic (DTA) diameter (45.8±14.3 mm vs. 38.2±7.5 mm, p=0.018) and higher incidence of penetrating aortic ulcer (PAU) on presenting CT angiography (52.0% vs 21.7%, p=0.033). Thirty day mortality was 2/25 (8.0%) for eTEVAR and 2/45 (4.4%) for dTEVAR (p=0.602). Postoperative aortic remodeling was more complete in the dTEVAR group (1.23±0.12 vs. 1.33±0.15, p=0.004). Case-control matching (controlling for presenting DTA diameter and PAU) on 30 patients still showed better aortic remodeling in the dTEVAR group (1.125±0.100 vs 1.348±0.42, p<0.001). The incidence of AREM was higher in the eTEVAR - 6/25 (24.0%) - group compared to the dTEVAR group - 2/46 (4.3%). At 12 months, freedom from AREM was higher in the dTEVAR group (95.7% vs. 76.0%, p=0.011). Postoperative TAD/TLD ratio was the best predictor for late aortic-related adverse events (AUROC=0.825, p=0.003).

CONCLUSION

TEVAR for acute type B IMH within 24 hours of admission is associated with lower aortic remodeling and higher occurrence of late aortic related adverse events and mortality. Delaying TEVAR when clinically possible could improve aortic remodeling and aortic-related outcomes.

Endovascular repair for retrograde type A intramural hematoma with focal intimal disruption in descending aorta

Background

This study aims to report the experience of a single center using thoracic endovascular aortic repair (TEVAR) to treat retrograde type A intramural hematoma (IMH) with focal intimal disruption (FID) in descending aorta.

Methods

A total of 24 consecutive patients with retrograde type A IMH and complicated with FID in descending aorta underwent TEVAR in our center from 2015 to 2020. Their clinical data, imaging manifestation and follow-up results were retrospectively reviewed and analyzed.

Results

The median age of patients was 57.9 years (range, 42–80 years) and 18 were men (75%). As the preoperative CT angiography showed, the 24 patients developed IMH complicated with different kinds of FIDs in descending aorta [5 had intramural blood pool (IBP), 15 had ulcer-like projection (ULP), 2 had penetrating atherosclerotic ulcer (PAU), and 5 had localized dissection]. Successful deployment of aortic stent graft was achieved in all patients. There was no endoleak, stent graft migration, spinal cord ischemia, stroke, or 30-day mortality observed after TEVAR. The median duration of follow-up was 30.0 months (range, 3–60 months). As the last follow-up CT angiography showed, most of the patients (23 in 24, 96%) had favorable aortic remodeling. The maximum hematoma thicknesses and maximum diameters of both ascending and descending aorta were significantly decreased. During follow-up, 1 patient developed retrograde type A aortic dissection (RAAD) and underwent open surgery 3 months after TEVAR. 1 patient died of lung cancer 2 years later. There was no aorta-related death observed.

Conclusions

TEVAR provides a safe and effective treatment strategy for selected patients with retrograde type A IMH, and FID developed in descending aorta could be the possible treatment target. However, RAAD remains one of the most serious postoperative complications of concern.

Using Machine Learning to Predict Five-Year Reintervention Risk in Type B Aortic Dissection Patients After Thoracic Endovascular Aortic Repair

Purpose: Type B aortic dissection (TBAD) is a high-risk disease, commonly treated with thoracic endovascular aortic repair (TEVAR). However, for the long-term follow-up, it is associated with a high 5-year reintervention rate for patients after TEVAR. There is no accurate definition of prognostic risk factors for TBAD in medical guidelines, and there is no scientific judgment standard for patients’ quality of life or survival outcome in the next five years in clinical practice. A large amount of medical data features makes prognostic analysis difficult. However, machine learning (ML) permits lots of objective data features to be considered for clinical risk stratification and patient management. We aimed to predict the 5-year prognosis in TBAD after TEVAR by Ml, based on baseline, stent characteristics and computed tomography angiography (CTA) imaging data, and provided a certain degree of scientific basis for prognostic risk score and stratification in medical guidelines. Materials and Methods: Dataset we recorded was obtained from 172 TBAD patients undergoing TEVAR. Totally 40 features were recorded, including 14 baseline, 5 stent characteristics and 21 CTA imaging data. Information gain (IG) was used to select features highly associated with adverse outcome. Then, the Gradient Boost classifier was trained using grid search and stratified 5-fold cross-validation, and Its predictive performance was evaluated by the area under the curve (AUC) in the receiver operating characteristic (ROC). Results: Totally 60 patients underwent reintervention during follow-up. Combing 24 features selected by IG, ML model predicted prognosis well in TBAD after TEVAR, with an AUC of 0.816 and a 95% confidence interval of 0.797 to 0.837. Reintervention rate of prediction was slightly higher than the actual (48.2% vs. 34.8%). Conclusion: Machine learning, which combined with baseline, stent characteristics and CTA imaging data for personalized risk computations, effectively predicted reintervention risk in TBAD patients after TEVAR in 5-year follow-up. The model could be used to efficiently assist the clinical management of TBAD patients and prompt high-risk factors.

False lumen pressure estimation in type B aortic dissection using 4D flow cardiovascular magnetic resonance: comparisons with aortic growth

BACKGROUND

Chronic type B aortic dissection (TBAD) is associated with poor long-term outcome, and accurate risk stratification tools remain lacking. Pressurization of the false lumen (FL) has been recognized as central in promoting aortic growth. Several surrogate imaging-based metrics have been proposed to assess FL hemodynamics; however, their relationship to enlarging aortic dimensions remains unclear. We investigated the association between aortic growth and three cardiovascular magnetic resonance (CMR)-derived metrics of FL pressurization: false lumen ejection fraction (FLEF), maximum systolic deceleration rate (MSDR), and FL relative pressure (FL ΔPmax).

METHODS

CMR/CMR angiography was performed in 12 patients with chronic dissection of the descending thoracoabdominal aorta, including contrast-enhanced CMR angiography and time-resolved three-dimensional phase-contrast CMR (4D Flow CMR). Aortic growth rate was calculated as the change in maximal aortic diameter between baseline and follow-up imaging studies over the time interval, with patients categorized as having either 'stable' (< 3 mm/year) or 'enlarging' (≥ 3 mm/year) growth. Three metrics relating to FL pressurization were defined as: (1) FLEF: the ratio between retrograde and antegrade flow at the TBAD entry tear, (2) MSDR: the absolute difference between maximum and minimum systolic acceleration in the proximal FL, and (3) FL ΔPmax: the difference in absolute pressure between aortic root and distal FL.

RESULTS

FLEF was higher in enlarging TBAD (49.0 ± 17.9% vs. 10.0 ± 11.9%, p = 0.002), whereas FL ΔPmax was lower (32.2 ± 10.8 vs. 57.2 ± 12.5 mmHg/m, p = 0.017). MSDR and conventional anatomic variables did not differ significantly between groups. FLEF showed positive (r = 0.78, p = 0.003) correlation with aortic growth rate whereas FL ΔPmax showed negative correlation (r = - 0.64, p = 0.026). FLEF and FL ΔPmax remained as independent predictors of aortic growth rate after adjusting for baseline aortic diameter.

CONCLUSION

Comparative analysis of three 4D flow CMR metrics of TBAD FL pressurization demonstrated that those that focusing on retrograde flow (FLEF) and relative pressure (FL ΔPmax) independently correlated with growth and differentiated patients with enlarging and stable descending aortic dissections. These results emphasize the highly variable nature of aortic hemodynamics in TBAD patients, and suggest that 4D Flow CMR derived metrics of FL pressurization may be useful to separate patients at highest and lowest risk for progressive aortic growth and complications.

Timing and Outcome of Endovascular Repair for Uncomplicated Type B Aortic Dissection

OBJECTIVE

This study aimed to determine the effect of intervention timing, from symptom onset to thoracic endovascular aortic repair (TEVAR), on early and late outcomes in high risk patients with uncomplicated type B aortic dissection (uTBAD).

METHODS

The study retrospectively evaluated 267 uTBAD patients with high risk radiographic features who underwent pre-emptive TEVAR during the acute and subacute periods. Demographics, comorbidities, pre-operative imaging features, peri-procedural details, and follow up outcomes were analysed.

RESULTS

Among the 267 pre-emptive TEVARs for high risk uTBAD, 130 were performed in the acute phase (1-14 days); and 137 in the subacute phase (15-90 days), from initial presentation. The mean age was 55.9 ± 11.0 years and 222 (83.1%) were men. The 30 day mortality rate in the acute group was five times higher than that in the subacute group (3.8% vs. 0.7%), although without statistically significant difference (p = .11). No statistically significant difference in 30 day outcomes (aortic rupture, retrograde type A dissection [RTAD], immediate type Ia endoleak, stroke, spinal cord ischaemia, and re-intervention) was noted (p > .05 for each). Of note, aortic rupture, RTAD, and disabling stroke were observed only in the acute group. Multivariable logistic analyses showed that intervention timing was not associated with 30 day outcomes. The median clinical follow up was 48.2 ± 25.9 months (range 1 - 106 months). There were no significant differences in all cause mortality, dissection related death, late intervention, or aortic related late events among timing cohorts (p > .05 for each). Furthermore, aortic remodelling, by analysing the flow status of the false lumen and evaluation of aortic diameters, either at the thoracic aorta level or the abdominal aorta level, was similar between the two groups. Multivariable Cox analyses showed that intervention timing was not associated with late outcomes.

CONCLUSION

The present study indicates that TEVAR for high risk uTBAD in the acute phase was associated with a trend toward higher rates of early complications, while the long term outcomes were comparable with those of the subacute phase.

TEVAR Stent to the False Lumen of a Chronic Type B Aortic Dissection With Aneurysmal Dilatation, When no Other Options Are Left

We report a case of a 72 years-old male referred to us with a 2-year history of an enlarging aortic aneurysm secondary to a chronic Type B aortic dissection and a complete occlusion of the true lumen in the thoracic and abdominal aorta except at the level of visceral arteries origins. Several attempts to recanalize the true lumen was not successful. Because of the patient's high risk for an open repair and the normal size of his thoracic aorta proximal to the celiac artery, we deployed the TEVAR stent to the false lumen to prevent aneurysmal enlargement and rupture. The operation was successful, and the patient recovered without complications and with complete exclusion of the aneurysm on two years follow up.

Effect of the urgency and landing zone on rates of in-hospital death, stroke, and paraplegia after thoracic endovascular aortic repair in Japan

OBJECTIVE

The present study used data from the Japanese Committee for Stentgraft Management's national registry, which contains unique surgical data, including surgical timing, anatomic factors, and pathologic factors, to determine the generalized community experience with thoracic endovascular abdominal aortic repair (TEVAR).

METHODS

The medical background and short-term outcomes were reviewed for patients who had undergone TEVAR for a thoracic aortic aneurysm (TAA; 14,235 cases) or aortic dissection (AD; 990 type A and 4259 type B) from 2008 to 2015. TEVAR for AD was separated from that for TAAs; only the background and short-term outcomes were evaluated. The technical outcomes of TEVAR for TAA were also evaluated. All the cases were categorized as follows: elective, urgent (within 24 hours after admission), or emergent (immediately after admission). The outcomes included in-hospital mortality and persistent stroke and paraplegia diagnosed at discharge. The number of debranching bypasses, proximal landing zone (0, 1, 2, ≥3), and zone length were included in the logistic regression analysis.

RESULTS

The mortality, stroke, and paraplegia rates in the TAA and AD groups were 4.4%, 4.6%, and 3.7% and 4.0%, 2.9%, and 2.8%, respectively. After analyzing the TAA cohort, we found that urgent and emergent cases were associated with all adverse outcomes. The rate of paraplegia increased drastically in the patients with stent graft coverage that extended for six or more zones. Massive atheroma was associated with stroke and paraplegia. The cumulative survival rate of the TAA group was stratified by the urgency (ie, elective, urgent, emergent; P < .001). We found that the more proximal (0, 1, and 2) the landing zone, the greater the risk of stroke. Likewise, the longer (six or more zones) the coverage, the greater the risk of paraplegia.

CONCLUSIONS

Urgency was strongly associated with mortality, stroke, and paraplegia, and the classification of urgent and emergent, according to the surgical timing after admission, successfully stratified the population in the long-term overall survival analysis. A proximal landing zone involving the aortic arch and debranching bypasses were associated with the occurrence of stroke, and the length of stent graft coverage for six or more zones was associated with paraplegia. Identifying these risk factors will help operators of TEVAR develop appropriate operative strategies to mitigate patient risk.

Aortic remodelling after thoracic endovascular aortic repair in acute and chronic type B aortic dissections

OBJECTIVES

Type B aortic dissections are routinely treated with thoracic endovascular aortic repair (TEVAR). The timing for TEVAR remains controversial and might have an impact on the remodelling capacity of the aorta. This study analyses and compares aortic remodelling in acute (ABD) and chronic (CBD) type B aortic dissections after TEVAR.

METHODS

This retrospective study analysed the preoperative, postoperative and at least 1-year follow-up computed tomography of 53 TEVAR patients (36 ABD, 17 CBD) at a single institution between May 2005 and May 2016. The volumes of aortic lumen (AL), true lumen, false lumen (FL) and perfused FL were measured at the stent graft level (A), from the stent graft to the coeliac trunk (B) and from the coeliac trunk to the bifurcation (C). The absolute volumes, normalized volume changes and FL thrombosis rate of ABD and CBD patients were compared.

RESULTS

Absolute AL and FL of segment A were significantly larger in CBD patients compared to ABD patients preoperatively (AL: 354 ± 68 vs 255 ± 51 ml, P = 0.023, FL: 253 ± 56 vs 183 ± 35 ml, P = 0.028) until last follow-up (AL: 462 ± 52 vs 246 ± 52 ml, P = 0.003, FL: 268 ± 202 vs 91 ± 31 ml, P = 0.004). The true lumen in segment A increased more in ABD than in CBD patients preoperatively to postoperatively (112% vs 36% P < 0.001) and within the first year postoperatively (171% vs 80% P < 0.001). FL in segment A decreased more in ABD compared to CBD patients within the first year (-42% vs -13% P < 0.001) and thereafter (-50% vs +6% P = 0.002). In segments B and C, the FL thrombosis rate was higher in ABD than in CBD patients at all time points and significantly higher in segment A after the first year (91% vs 98% P = 0.035).

CONCLUSIONS

Aortic remodelling after TEVAR is significantly different in acute and chronic dissection patients. TEVAR promotes aortic remodelling in both acute and chronic dissections in terms of true lumen increase at stent graft level. Nevertheless, significant AL reduction by FL shrinkage is primarily found in ABD.

Management of acute type B aortic dissection

BACKGROUND

The best management of acute uncomplicated type B aortic dissection is currently a controversial area. Recent advances in endovascular intervention have begun to establish pre-emptive thoracic endovascular aortic repair as a potential strategy. A review about the management for type B aortic dissection has been conducted.

METHODS

A narrative review consisting of 157 original articles, meta-analyses and guidelines was conducted. The findings were synthesized and summarized using 70 articles.

RESULTS

There are clear guidelines directing surgical management of acute complicated type B aortic dissection. However, the best management of acute uncomplicated disease is more ambiguous, which is especially concerning in a condition which is associated with significant morbidity and mortality. Medical management alone is generally favoured. Endovascular intervention is now being considered by some surgeons, but it can be technically difficult, while exposing the patient to potential surgical risks.

CONCLUSIONS

Clinical and anatomical risk factors have been identified to help vascular surgeons make decisions about treatment in acute uncomplicated type B aortic dissection. New endovascular strategies are being developed to reduce surgical risk and address technical challenges. Registry data should be used to support future best management.

Clinical and Morphologic Outcomes of Endovascular Repair for Subacute and Chronic Type B Aortic Dissection

BACKGROUND

The objective of the study was to assess long-term remodeling, survival, and reintervention outcomes after thoracic endovascular aortic repair (TEVAR) for subacute and chronic type B aortic dissection (TBAD).

METHODS

All patients who underwent TEVAR for subacute or chronic TBAD at a tertiary referral center between 1999 and 2015 were included in this cohort study. The primary outcome was aortic remodeling, and secondary outcomes included survival, rate of major complications, and reinterventions.

RESULTS

Fifty patients were included, with mean age of 62.4 years, 10 (20%) DeBakey type IIIA and 40 (80%) DeBakey type IIIB dissection; 45 standard TEVAR, 2 branched TEVAR, 3 TEVAR combined with fenestrated or branched EVAR. Indication for TEVAR was intact (n = 40) or ruptured (n = 1) postdissection aneurysm, hypoperfusion (n = 4), treatment-refractory pain (n = 2), or a combination (n = 3). Mean clinical follow-up was 76 months, and median radiological follow-up was 46 months. Thirty-day survival was 96%, stroke 4%, renal failure 0%, paraplegia 0%. Three- and five-year survival was 92% (95% confidence interval (CI) [79; 97]) and 77% (95% CI [61; 87]), respectively. Of 19 late deaths, 6 were confirmed aorta related. Five-year freedom from reintervention was 69% (95% CI [53-80]). Distal stent graft extension due to aortic dilatation composed most reinterventions. Mean maximal aortic diameter was 58.7 mm preoperatively and 51.9 mm on last follow-up (P = 0.003). On thoracic level, true lumen expanded (+10.0 mm, 95% CI [6.4; 13.6]) (P < 0.001) and false lumen decreased (-11.9 mm, 95% CI [-15.2; -8.5]) (P < 0.001) from baseline to the last computed tomography. In the abdominal aorta, true lumen diameter change was +3.1 mm (95% CI [1.4; 4.8]) (P = 0.001); false lumen diameter change was +1.0 mm (95% CI [-1.8; 3.8]) (P = 0.464).

CONCLUSIONS

TEVAR for subacute and chronic TBAD results in favorable remodeling of the thoracic but not the abdominal aorta. Five-year survival is almost 80%, but late aortic deaths still occur. Aortic dilatation distal to the treated segment requiring reintervention is common, emphasizing the importance of follow-up.

Timing of thoracic endovascular aortic repair for uncomplicated acute type B aortic dissection and the association with complications

OBJECTIVE

Previous publications have clearly established a correlation between timing of thoracic endovascular aortic repair (TEVAR) and complications after treatment of complicated acute type B aortic dissection (ATBAD). However, the temporal association of TEVAR with morbidity after uncomplicated presentations is poorly understood and has not previously been examined using real-world national data. Therefore, the objective of this analysis was to determine whether TEVAR timing of uncomplicated ATBAD (UATBAD) is associated with postoperative complications.

METHODS

The Vascular Quality Initiative TEVAR and complex endovascular aneurysm repair registry was analyzed from 2010 to 2019. Procedures performed for non-dissection-related disease as well as for ATBAD with malperfusion or rupture were excluded. Because of inherent differences between timing cohorts, propensity score matching was performed to ensure like comparisons. Univariate and multivariable analysis after matching was used to determine differences between timing groups (symptom onset to TEVAR: acute, 1-14 days; subacute, 15-90 days) for postoperative mortality, in-hospital complications, and reintervention.

RESULTS

A total of 688 cases meeting inclusion criteria were identified. After matching 187 patients in each of the 1- to 14-day and 15- to 90-day treatment groups, there were no statistically significant differences between groups. On univariate analysis, the 1- to 14-day treatment group had a higher proportion of cases requiring reintervention within 30 days (15.3%) compared with UATBAD patients undergoing TEVAR within 15 to 90 days (5.2%; P = .02). There was also a difference (P = .007) at 1 year, with 33.8% of the 1- to 14-day UATBAD patients undergoing reintervention compared with 14.5% for the 15- to 90-day group. There were no statistically significant differences on multivariable analysis for long-term survival, complications, or long-term reintervention. There was a trend toward significance (P = .08) with the 1- to 14-day group having 2.3 times the odds of requiring an in-hospital reintervention compared with the 15- to 90-day group.

CONCLUSIONS

Timing of TEVAR for UATBAD does not appear to predict mortality or postoperative complications. However, there is a strong association between repair within 1 to 14 days and higher risk of reintervention. This may in part be related to the 1- to 14-day group's representing an inherently higher anatomic or physiologic risk population that cannot be entirely accounted for with propensity analysis. The role of optimal timing to intervention should be incorporated into future study design of TEVAR trials for UATBAD.

Cause-specific mortality of type B aortic dissection and assessment of competing risks of mortality

OBJECTIVE

Natural history studies of type B aortic dissection (TBAD) commonly report all-cause mortality. Our aim was to determine cause-specific mortality in TBAD and to evaluate the clinical characteristics associated with aorta-related and nonaorta-related mortality.

METHODS

Clinical and administrative records were reviewed for patients with acute TBAD between 1995 and 2017. Demographics, comorbidities, presentation, and initial imaging findings were abstracted. Cause of death was ascertained through a multimodality approach using electronic health records, obituaries, social media, Social Security Death Index, and state mortality records. Causes of death were classified as aorta related, nonaorta related, or unknown. A Fine-Gray multivariate competing risk regression model for subdistribution hazard ratio was employed to analyze the association of clinical characteristics with aorta-related and nonaorta-related mortality.

RESULTS

A total of 275 individuals met inclusion criteria (61.1 ± 13.7 years, 70.9% male, 68% white). Mean survival after discharge was 6.3 ± 4.7 years. Completeness of follow-up Clark C index was 0.87. All-cause mortality was 50.2% (n = 138; mean age, 70.1 ± 14.6 years) including an in-hospital mortality of 8.4%. Cause-specific mortality was aorta related, nonaorta related, and unknown in 51%, 43%, and 6%, respectively. Compared with patients with nonaorta-related mortality, patients with aorta-related mortality were younger at acute TBAD (69.5 ± 11.2 years vs 61.6 ± 15.5 years; P = .001), underwent more descending thoracic aortic repairs (19.4% vs 45.8%; P = .002), and had a shorter survival duration (5.7 ± 3.9 vs 3.4 ± 4.5 years; P = .002). There was clear variation in cause of death by each decade of life, with higher aorta-related mortality among those younger than 50 years and older than 70 years and a stepwise increase in nonaorta-related mortality with each increasing decade (P < .001). All-cause mortality at 1 year, 3 years, and 10 years was 15%, 24%, and 57%, respectively. After accounting for competing risks, the cumulative incidence of aorta-related mortality at 1 year, 3 years, and 10 years was 8.9%, 16.5%, and 27.2%, respectively, and that of nonaorta-related mortality was 2.7%, 7.2%, and 29%, respectively. A maximum descending thoracic aortic diameter >4 cm was associated with an increase in hazard of aorta-related mortality by 84% (subdistribution hazard ratio, 1.84; 95% confidence interval, 1.03-3.28) on multivariate competing risk regression analysis.

CONCLUSIONS

TBAD is associated with high 10-year mortality. Those at risk for aorta-related mortality have a clinical phenotype different from that of individuals at risk for nonaorta-related mortality. This information is important for building risk prediction models that account for competing mortality risks and to direct optimal and individualized surgical and medical management of TBAD.

Endovascular management of chronic post-dissection aneurysms of the aortic arch

This article reviews endovascular management of chronic post-dissection aneurysms of the aortic arch. Therapeutic strategies intended for this complex aortic condition are evolving rapidly to allow the treatment of various hostile aortic anatomy and frail patients. Principles, technical considerations, devices and outcomes of each technique are reviewed and summarized. Hybrid repair offer similar early mortality and stroke rates compared to open conventional surgery. Arch chimney and other parallel graft techniques present poor long term outcome, and should be limited to emergency situations where no other option is available. Fenestrated stent-grafting is subjected to many technical challenges in aortic arch due to difficulties in stent-graft orientation and fenestration positioning. In situ fenestration is an off-label technique that should only be used as an emergency bailout maneuver, considering that temporary coverage of supra aortic trunk vessel and its long-term durability raise concern. Finally, in experienced hands and appropriate anatomic conditions, arch branched graft technology has shown itself to be a safe and effective alternative to open conventional surgery. No randomized controlled trials have yet compared total endovascular aortic arch repair with hybrid techniques and open arch repair. The management of chronic post-dissection aneurysms of the aortic arch is challenging, decision-making and interventions should continue to be performed in high-volume centers with a dedicated aortic team with an expertise in both open and endovascular repairs.

Endovascular Aneurysm Repair With Re-entry Closure in a Patient With Abdominal Aortic Aneurysm Concomitant With Acute Type B Aortic Dissection

Introduction

Abdominal aortic aneurysm (AAA) concomitant with acute aortic dissection is rare.

Case report

An acute type B aortic dissection involving AAA in a 58 year old woman is described. Computed tomography angiography demonstrated that the false lumen of the abdominal aorta including the aneurysm remained patent, secondary to entry sites in the abdominal aorta, bilateral external iliac arteries, and a membrane tear of the left renal artery (LRA). The aneurysm was isolated by endovascular aneurysm repair and LRA stenting; all entry sites were occluded by endovascular treatment that included covered stenting of the LRA. Imaging performed three months after the procedure confirmed complete thrombosis of the false lumen and AAA sac shrinkage.

Discussion

Endovascular treatment with covered stents is reported as an alternative strategy for treatment of AAA concomitant with acute aortic dissection involving a visceral artery.

•

A 58 year old woman developed acute type B aortic dissection involving an AAA.

•

AAA concomitant with acute aortic dissection is rare.

•

Endovascular treatment using a covered stent of the visceral artery can be effective.

Assessing Aortic Remodeling after Thoracic Endovascular Aortic Repair (TEVAR) in DeBakey IIIb Aortic Dissection: A Retrospective Study

PURPOSE

This study analyzed the different levels of aortic remodeling in patients with DeBakey IIIb aortic dissection (AD) after thoracic endovascular aortic repair (TEVAR) at a single center.

METHODS

In all, 66 patients with DeBakey IIIb AD who underwent TEVAR in the acute (Group A) or subacute phase (Group SA) from January 2012 to October 2016 were included in the study. The change in aortic lumen (A), true lumen (TL), false lumen (FL), and true lumen index (TLi) at different levels were analyzed.

RESULTS

There was no statistically significant difference in the clinical information and morphologic imaging findings in Groups A and SA. At proximal levels (levels A-C), there was no difference in aortic remodeling parameters, that is, increased TL, decreased FL, and increased TLi at levels B and C and stable A at levels A-C, in both groups. Moreover, the above parameters were illustrated using a box-and-whisker plot, which revealed the unstable acute phase by the larger distribution interval and the median and abnormal values of the right skew distribution in Group A.

CONCLUSION

Postoperative surveillance is important for patients of both acute and subacute AD.