Favorable impact of thoracic endovascular aortic repair on survival of patients with acute uncomplicated type B aortic dissection.

BACKGROUND: In uncomplicated type B aortic dissection (UTBAD), the "gold standard" has been nonoperative treatment with medical therapy, although this has been questioned by studies demonstrating improved outcomes in those treated with thoracic endovascular aortic repair (TEVAR). This study assessed long-term survival after acute UTBAD comparing medical therapy, open repair, and TEVAR. METHODS: The California Office of Statewide Hospital Planning Development database was analyzed from 2000 to 2010 for adult patients with acute UTBAD. Patients with nonemergent admission for aortic dissection, type A dissection, trauma, bowel ischemia, lower extremity ischemia, acidosis, or shock were excluded. The cohort was stratified by treatment type at index admission into medical therapy, open surgical repair, and TEVAR. Multivariable regression and survival analyses were used to evaluate the association of treatment type with long-term overall survival. RESULTS: There were 9165 cases, 95% medical therapy, 2% open repair, and 2.9% TEVAR. The mean age was 66 ± 15 years, with 39% female, 2.4% cocaine users, 18% with congestive heart failure, and 17% with Charlson Comorbidity Index >3. Mean inpatient costs were $57,000 for medical therapy, $200,000 for open repair, and $130,000 for TEVAR (P < .01). Inpatient mortality was 6.5% overall, 6.3% for medical therapy, 14% for open repair, and 7.1% for TEVAR (P < .01). One-year and 5-year survivals were 84% and 60% in medical therapy, 76% and 67% in open repair, and 85% and 76% in TEVAR (log-rank, P < .01). On risk-adjusted multivariable analysis, TEVAR had improved survival compared with medical therapy (hazard ratio, 0.68; 95% confidence interval, 0.6-0.8; P < .01), with no difference between open repair and medical therapy (hazard ratio, 1.0; 95% confidence interval, 0.8-1.3; P < .01). CONCLUSIONS: This statewide study on survival after acute UTBADs shows an independent survival advantage for TEVAR over medical therapy. These data add further evidence for a paradigm shift in acute management of type B dissection in favor of early TEVAR.

Treatment of uncomplicated type B aortic dissection.

Hospital mortality after the replacement of chronic type B aortic dissection is around 8-10% and adverse outcomes include paraplegia and stroke. However, the level of evidence for indication of thoracic endovascular aortic repair (TEVAR) for type B chronic aortic dissection is Class IIa. Results of the INSTEAD-XL trial have verified that preemptive TEVAR for uncomplicated type B aortic dissection improves prognosis. The indication for this procedure is reportedly a maximum aortic diameter >40 mm during the acute phase and a patent primary entry site in the thoracic aorta, while the optimal timing for TEVAR would be the subacute phase, from 2 weeks to 3-6 months after onset. Prevention of chronic type B aortic dissection with aneurysmal degeneration and attainment of aortic remodeling with preemptive TEVAR are needed to free patients from the need for long-term strict control of blood pressure and periodic follow-ups involving radiological exposure and to avoid the eventual need for extensive open surgery.