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TEVAR in Uncomplicated Type B Aortic Dissection: A Retrospective Propensity-Matched Evaluation of Complications and Aneurysmal Degeneration
Ahmad Tabatabaeishoorijeh
1, Maham Rahimi
2 1Texas A&M School of Engineering Medicine (ENMED), Houston, TX;
2Department of Cardiovascular Surgery, Houston Methodist Hospital, Houston, TX
BACKGROUND: TEVAR is widely used for type B aortic dissections (TBAD), but its efficacy in uncomplicated cases (UTBAD) is unclear. This study compares complications, such as aneurysmal degeneration and malperfusion, between medically managed UTBAD patients and those undergoing acute (1-14 days) or subacute (14-90 days) TEVAR.
METHODS: We retrospectively analyzed patients who underwent TEVAR for descending thoracic and thoracoabdominal aortic dissections between August 1994 and August 2024 using the TriNetX database. Patients were categorized into acute TEVAR (1-14 days), subacute TEVAR (14-90 days), and medical management groups. We excluded those with a history of malperfusion or prior thoracic/thoracoabdominal aneurysm or rupture. Outcomes—including mortality, rupture, aneurysmal degeneration, and malperfusion—were compared pre- and post-propensity score matching at various intervals. Kaplan-Meier analysis estimated 10-year freedom from aneurysmal degeneration in matched cohorts.
RESULTS: A total of 19,008 patients with uncomplicated thoracic and thoracoabdominal aortic dissections met the inclusion criteria: 914 (4.8%) managed with acute TEVAR, 207 (1.1%) with subacute TEVAR, and 17,887 (94.1%) with medical management. Propensity score matching resulted in 912 patients for acute TEVAR versus medical management, and 205 patients for subacute TEVAR versus medical management. Acute TEVAR showed significantly higher mortality at 1 month compared to medical management (6.7% vs 3.7%; P = .004), a trend that persisted up to 5 years. The acute TEVAR group also had higher rates of acute kidney injury at 1 month (2.8% vs 1.3%; P = .022), though this did not persist beyond 3 years. Thoracic aortic rupture risk was similar at 1 month but became significantly higher in acute TEVAR by 3 years (2.3% vs 1.1%; P = .046). Aneurysmal degeneration was significantly higher at 1 month for acute TEVAR compared to medical management (4.1% vs 1.1%; P < .001) and persisted throughout 5 years (Table 1). For subacute TEVAR, mortality rates were similar to medical management across all intervals up to 5 years, with no significant differences in malperfusion rates or rupture risk. However, aneurysmal degeneration risk became significantly higher in subacute TEVAR group by 6 months compared to medical management (10.1% vs 4.9%; P = .049) and remained elevated up to 5 years (Table 2). Acute and subacute TEVAR had significantly lower 10-year freedom from aneurysmal degeneration compared to medical management (82.4% vs 85.6%; P = .003 for acute; 60.7% vs 92.4%; P = .002 for subacute).
CONCLUSIONS: In UTBAD, acute TEVAR is linked to higher early mortality, acute kidney injury, and greater risks of aneurysmal degeneration and aortic rupture compared to medical management. Subacute TEVAR has similar mortality and malperfusion but increases the risk of aneurysmal degeneration by 6 months. These findings emphasize the need to carefully consider and time TEVAR to balance short-term risks with long-term outcomes.
Interval outcomes for 912 matched patients: Acute TEVAR (%) vs. medical management (%) (P value)| Outcome | 1 Month | 3 Month | 6 Month | 1 Year | 3 Year | 5 Year |
| Mortality | 6.7% vs 3.7% (.004) | 7.6% vs 4.8% (.012) | 8.7% vs 5.4% (.005) | 10.3% vs 6.8% (.007) | 13.6% vs 10.1% (.020) | 16.4% vs 12.5% (.016) |
| Acute Kidney Injury | 2.8% vs 1.3% (.022) | 3.5% vs 1.6% (.012) | 3.8% vs 2.2% (.040) | 4.3% vs 2.5% (.039) | 5.5% vs 4.3% (.232) | 6.1% vs 5.1% (.357) |
| Thoracic Aneurysmal Degeneration | 4.1% vs 1.1% (<.001) | 6.6% vs 1.6% (<.001) | 7.5% vs 1.9% (<.001) | 9.1% vs 3.1% (<.001) | 10.4% vs 5.7% (<.001) | 10.8% vs 6.6% (.001) |
| Thoracic Aortic Rupture | 1.1% vs 1.1% (1.0) | 1.7% vs 1.1% (.236) | 1.8% vs 1.1% (.174) | 2.1% vs 1.1% (.092) | 2.3% vs 1.1% (.046) | 2.3% vs 1.1% (.046) |
Interval outcomes for 205 matched patients: Subacute TEVAR (%) vs. medical management (%) (P value)| Outcome | 1 Month | 3 Month | 6 Month | 1 Year | 3 Year | 5 Year |
| Mortality | 4.9% vs 4.9% (1.0) | 4.9% vs 4.9% (1.0) | 5.4% vs 6.8% (.536) | 6.3% vs 7.3% (.695) | 7.8% vs 11.7% (.183) | 11.7% vs 15.1% (.310) |
| Acute Kidney Injury | 4.9% vs 4.9% (1.0) | 4.9% vs 4.8% (.982) | 4.9% vs 4.8% (.982) | 4.9% vs 4.8% (.982) | 5.4% vs 7.3% (.432) | 6.4% vs 7.8% (.582) |
| Thoracic Aneurysmal Degeneration | 6.9% vs 4.9% (.397) | 8.4% vs 4.9% (.152) | 10.1% vs 4.9% (.049) | 10.6% vs 4.9% (.033) | 12.2% vs 4.9% (.009) | 12.7% vs 5.8% (.018) |
| Thoracic Aortic Rupture | 4.9% vs 0.0% (.001) | 4.9% vs 4.9% (1.0) | 4.9% vs 4.9% (1.0) | 4.9% vs 4.9% (1.0) | 4.9% vs 4.9% (1.0) | 4.9% vs 4.9% (1.0) |
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