Comparison of long-term clinical outcome between patients with chronic versus acute type B aortic dissection treated by implantation of a stent graft: a single-center report

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.

Thoracic endovascular repair of chronic type B aortic dissection: a systematic review

BACKGROUND

At present, the optimal management strategy for chronic type B aortic dissection (CTBAD) remains unknown, as equipoise remains regarding medical management versus endovascular treatment versus open surgery. However, the results over recent years of thoracic endovascular aortic repair (TEVAR) in CTBAD appear promising. The aim of this systematic review was to provide a comprehensive analysis of the available data reporting outcomes and survival rates for TEVAR in CTBAD.

METHODS

Electronic searches of six databases were performed from inception to April 2021. All studies reporting outcomes, specifically 30-day mortality rates, for endovascular repair of CTBAD were identified. Relevant data were extracted, and a random-effects meta-analysis of proportions or means was performed to aggregate the data. Survival data were pooled using data derived from original Kaplan-Meier curves, which allows reconstruction of individual patient data.

RESULTS

Forty-eight studies with 2,641 patients were identified. Early (<30 days) all-cause and aortic-related mortality rates were low at 1.6% and 0.5%, respectively. Incidence of retrograde type A dissection in the post-operative period was only 1.4%. There were also low rates of cerebrovascular accidents and spinal cord injury (1.1% and 0.9%, respectively). Late follow-up all-cause mortality was 8.0%, however, late aortic-related mortality was only 2.4%. Reintervention rates were 10.1% for endovascular and 6.7% for surgical reintervention. Pooled rates of overall survival at 1-, 3-, 5- and 10-year were 91.5%, 84.7%, 77.7% and 56.3%, respectively.

CONCLUSIONS

The significant heterogeneity in the available evidence and absence of consensus reporting standards are important considerations and concern when interpreting the data. Evaluation of the evidence suggests that TEVAR for CTBAD is a safe procedure with low rates of complications. However, the optimal treatment strategy for CTBAD remains debatable and requires further research. Evidence from high-quality registries and clinical trials are required to address these challenges.

Early and midterm outcomes of thoracic endovascular aortic repair (TEVAR) for acute and chronic complicated type B aortic dissection

Thoracic endovascular aortic repair (TEVAR) in the current era has been chosen as a dominant and minimally invasive treatment for complicated aorta dissection. This study aimed to assess safety and feasibility of TEVAR in acute and chronic type B aortic dissection.Between January 2011 and December 2013, 85 patients with complicated type B aortic dissection undergoing TEVAR were divided into acute aortic dissection (AAD) (n = 60) group and chronic aortic dissection (CAD) group (n = 25). Computed tomography was used to evaluate postoperative changes in maximal aortic diameter and true and false lumen diameters at 3 levels during a mean follow-up period of 26.4 ± 15.6 months.The technical success rate was 100%. In-hospital and 30-day rates of death were 3.3% in acute group and 0 in chronic group. Postdischarge rates of type I leak, type II leak, and retrograde type A dissection were 6.7%, 5.2%, and 3.4% (acute) and 0%, 4.0%, and 4.0% (chronic), respectively. The maximal aorta diameter remained stable in all the 3 levels in both acute and chronic group. The cumulative freedom from all-cause mortality at 3 years was similar in acute and chronic groups (89.5% vs 95.5%, P = .308). The cumulative freedom from aortic-related mortality was also not significantly different in the acute and chronic groups (92.8% vs 95.2%, P = .531). In the thoracic aorta, TEVAR treatment resulted in a significant increase in true lumen (TL) diameter and decrease in false lumen (FL). However, in the abdominal aorta, TEVAR did not lead to significant change in TL and FL diameters. The rates of complete thrombosis thoracic false lumens were better than that in the abdominal false lumen.TEVAR was a safe and effect therapy for complicated acute and chronic type B dissection with low early and mid-term mortality and morbidity.

Frozen Elephant Trunk and Antegrade Visceral Debranching in the Surgical Treatment of Type B Aortic Dissection: An Alternative Method

Intervention is inevitable in complicated Type B aortic dissections. Classical surgical procedures and endovascular interventions are far from ideal treatments due to their high risk of periprocedural complications and mortality. There is often a need for alternative method in cases of difficult anatomy. We present the combined use of frozen elephant trunk and antegrade visceral debranching methods in the treatment of a 54-year-old male patient with complicated Type B aortic dissection.

Contemporary endovascular treatment of type B aortic dissection in China

OBJECTIVE

Endovascular stent-grafts have been used in China to treat type B aortic dissection since 1999, and there is a plethora of cohort studies in the contemporary literature. The aim of this review was to analyse the published results of endovascular treatment for type B aortic dissection in China.

METHOD

A systematic literature review of all published literature from January 1999 to October 2014 on endovascular treatment of type B aortic dissection in China was undertaken using PubMed, Medline, and the Chinese National Knowledge Infrastructure databases.

RESULTS

Seventy papers were retrieved (4 English, 66 Chinese) with a total of 4208 patients; 3396 (80.7%) were male, and the mean age ranged from 43 to 65 years. Procedural success was reported in 99.4% ± 1.7%. Complications were reported in 14.6% ± 11.1%, with major complications in 1.7% ± 2.9%, and the most devastating neurologic complications in 1.1% ± 2.2% (stroke 0.9% ± 2.4%, paraplegia 1.5% ± 0.7%). Postoperative endoleak occurred in 8.1% ± 7.6%. The 30-day postoperative mortality was 2.4% ± 3.3%. During follow-up, false-lumen thrombosis occurred in 92.1% ± 11.7%. Reintervention was performed in 1.3% ± 3.3%. The incidence of proximal and distal stent-graft-induced new entry was 0.5% ± 1.3% and 0.9% ± 2.7%, respectively, with endoleak in 2.7% ± 4.4% and mortality of 2.2% ± 3.2%.

CONCLUSIONS

Current evidence suggests that use of endovascular stent-grafts for type B aortic dissection in China is feasible and safe with low rates of perioperative complications and short-term mortality. However, a standardised reporting system and long-term follow-up data are lacking.

Contemporary Management Strategies for Chronic Type B Aortic Dissections: A Systematic Review

Background

Currently, the optimal management strategy for chronic type B aortic dissections (CBAD) is unknown. Therefore, we systematically reviewed the literature to compare results of open surgical repair (OSR), standard thoracic endovascular aortic repair (TEVAR) or branched and fenestrated TEVAR (BEVAR/FEVAR) for CBAD.

Methods

EMBASE and MEDLINE databases were searched for eligible studies between January 2000 and October 2015. Studies describing outcomes of OSR, TEVAR, B/FEVAR, or all, for CBAD patients initially treated with medical therapy, were included. Primary endpoints were early mortality, and one-year and five-year survival. Secondary endpoints included occurrence of complications. Furthermore, a Time until Treatment Equipoise (TUTE) graph was constructed.

Results

Thirty-five articles were selected for systematic review. A total of 1081 OSR patients, 1397 TEVAR patients and 61 B/FEVAR patients were identified. Early mortality ranged from 5.6% to 21.0% for OSR, 0.0% to 13.7% for TEVAR, and 0.0% to 9.7% for B/FEVAR. For OSR, one-year and five-year survival ranged 72.0%-92.0% and 53.0%-86.7%, respectively. For TEVAR, one-year survival was 82.9%-100.0% and five-year survival 70.0%-88.9%. For B/FEVAR only one-year survival was available, ranging between 76.4% and 100.0%. Most common postoperative complications included stroke (OSR 0.0%-13.3%, TEVAR 0.0%-11.8%), spinal cord ischemia (OSR 0.0%-16.4%, TEVAR 0.0%-12.5%, B/FEVAR 0.0%-12.9%) and acute renal failure (OSR 0.0%-33.3%, TEVAR 0.0%-34.4%, B/FEVAR 0.0%-3.2%). Most common long-term complications after OSR included aneurysm formation (5.8%-20.0%) and new type A dissection (1.7–2.2%). Early complications after TEVAR included retrograde dissection (0.0%-7.1%), malperfusion (1.3%–9.4%), cardiac complications (0.0%–5.9%) and rupture (0.5%–5.0%). Most common long-term complications after TEVAR were rupture (0.5%–7.1%), endoleaks (0.0%–15.8%) and cardiac complications (5.9%-7.1%). No short-term aortic rupture or malperfusion was observed after B/FEVAR. Long-term complications included malperfusion (6.5%) and endoleaks (0.0%-66.7%). Reintervention rates after OSR, TEVAR and B/FEVAR were 5.8%-29.0%, 4.3%-47.4% and 0.0%-53.3%, respectively. TUTE for OSR was 2.7 years, for TEVAR 9.9 months and for B/FEVAR 10.3 months.

Conclusion

We found a limited early survival benefit of standard TEVAR over OSR for CBAD. Complication rates after TEVAR are higher, but complications after OSR are usually more serious. Initial experiences with B/FEVAR show its feasibility, but long-term results are needed to compare it to OSR and standard TEVAR. We conclude that optimal treatment of CBAD remains debatable and merits a patient specific decision. TUTE seems a feasible and useful tool to better understand management outcomes of CBAD.

Influence of distal extension of false lumen on adverse aortic events after TEVAR in patients with acute type B aortic dissection

OBJECTIVE

To investigate the clinical outcomes influenced by distal extension of false lumen in acute type B aortic dissection (TBAD) patients following thoracic endovascular aortic repair (TEVAR).

METHODS

From April 2002 to January 2013, 264 TBAD patients treated with TEVAR were retrospectively enrolled. The IIIa group exhibited a distal false lumen above the diaphragm (n = 70), and the IIIb group exhibited a distal false lumen under the diaphragm (n = 194). The morphological characteristics and adverse events (30-day and >30 days) were recorded and evaluated.

RESULTS

There were no significant differences between the two groups regarding the demographics, comorbidity profiles, or initial feature of computed tomography angiography. The incidence of true lumen compression and branch involvement were significantly increased in the IIIb group compared with the IIIa group (8.6% vs. 25.3%, respectively; 15.7% vs. 36.1%, respectively, both P < 0.05). The 30-day mortality rate was 1.0% (2/194) in the IIIb group, whereas the IIIa group was zero. The incidence of early adverse events, the 5-year cumulative freedom from adverse events, and the 5-year cumulative freedom from all-cause mortality rate were not significantly different between the IIIa and IIIb groups (2.9% vs. 6.7%, 81.4%, and 80.4%, and 95.7% vs. 93.8%, respectively, all P > 0.05). Log-rank tests also indicated there was no significant difference.

CONCLUSIONS

There was no significant difference between the IIIa and IIIb groups in the 5-year morality and adverse aortic events following TEVAR. The distal extension of false lumen prior to TEVAR does not influence the long-term morality and adverse aortic events in acute TBAD.