Outcomes of Complicated, High Risk and Uncomplicated Acute Type B Aortic Dissections Treated with Thoracic Endovascular Aortic Repair
Amanda C Filiberto1, Ali Azizzadeh2, Richard Cambria3, Jack Cronenwett4, Mark Fillinger4, John Kern5, Joseph Lombardi6, Grace Wang7, Rodney White8, Adam Beck1
1University of Alabama, Birmingham, AL;2Cedar Cinai, Los Angeles, AL;3St. Elizabeth's Medical Center, Brighton, MA;4Dartmouth-Hitchcock Medical Center, Lebanon, NH;5University of Virginia, Charlottesville, VA;6Cooper Hospital, Camden, NJ;7University of Pennsylvania, Philadelphia, PA;8Long Beach Memorial Heart and Vascular, Long Beach, CA
Objective: Recently the Society for Vascular Surgery (SVS) and the Society for Thoracic Surgery (STS) published contemporary guidelines defining complicated vs uncomplicated type B aortic dissections (TBADs), and included previously undefined “high risk” features that might have prognostic significance. The impact of these high-risk features on outcomes of thoracic endovascular aortic repair (TEVAR) have not been fully evaluated. The objective of this study was to evaluate the SVS Vascular Quality Initiative (VQI) postapproval study (VQI PAS) data for the impact of TEVAR on early and late outcomes, including mortality, procedural complications, and long-term reintervention, stratified by acuity of dissection and presence of high-risk features. Methods: The VQI PAS used for this analysis includes a total of 711 patients with data collected from 2013 to 2023. Patients were stratified by aortic dissection acuity: complicated (cTBAD: defined as those with rupture or malperfusion) (N= 209), high-risk (hrTBAD: defined as refractory pain/hypertension, aortic diameter >40mm) (N=481) and uncomplicated (uTBAD: defined as those without rupture or malperfusion or high-risk features) (N=21). Univariate and multivariable analysis were used to determine differences in outcomes by aortic dissection acuity for postoperative mortality, in-hospital complications, and reintervention. Results: Demographics and comorbid conditions were similar across the 3 groups. Preoperative HTN as well as ASA, statin, ACE, and β blocker use were more common in the uTBAD group. Postoperative complications, including intestinal ischemia, stroke, new need for dialysis, dysrhythmia, permanent spinal cord ischemia, and respiratory complications were more common in the cTBAD group. There were no differences in postoperative complications or mortality between uTBAD when compared with hrTBAD. Unadjusted procedure related in-hospital mortality was lowest in the uTBAD group (0%, 2%, and 11%; P = <.001), as was 1-year mortality (0%, 10%, and 24%; P = <.001). Procedure related reintervention was highest in the cTBAD group (5%, 7%, and 13%; P = .027). On KM analysis, there is a marked separation in survival after TEVAR by group (log rank= .001), but no differences in reintervention. Conclusions: TEVAR for truly uncomplicated dissection was rare in the data set. High risk features, as defined by the STS/SVS guidelines, were not associated with poorer early outcomes after TEVAR, but were associated with higher mortality at 1-year. Unsurprisingly, patients with acute cTBADs undergoing TEVAR have poorer perioperative and long-term outcomes when compared to both uTBAD or hrTBADs. These findings may improve preoperative surgical risk stratification and patient counselling.
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