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Impact Of Aortic Visceral Branch Vessel Interventions On The Postoperative Outcomes Of Type B Aortic Dissection Complicated With Visceral Malperfusion
Narek Veranyan, Omar Al-Nouri, John Lane, Mahmoud B. Malas
UC San Diego Health, La Jolla, CA
INTRODUCTION: Thoracic Endovascular Aortic Repair (TEVAR) is the standard of care for type B aortic dissection (TBAD) complicated with visceral malperfusion. TEVAR covers the intimal tear and redirects the blood flow into the true lumen, depressurizing the false lumen. TEVAR alone sometimes resolves the visceral malperfusion, but some patients undergo adjunctive VBV interventions to maintain antegrade blood flow after deployment of the aortic stent graft. No robust data exists comparing the clinical outcomes of TEVAR with vs without adjunctive VBV interventions in TBAD patients presenting with visceral malperfusion. This study aims to compare the postoperative outcomes of TEVAR with vs without VBV interventions in patients with visceral malperfusion in a real-world multi-institutional setting.
METHODS: The Society for Vascular Surgery (SVS) Vascular Quality Initiative (VQI) database was reviewed for patients who underwent TEVAR for TBAD complicated with intestinal or renal malperfusion. The cohort was divided into two groups: TEVAR with vs without adjunctive VBV intervention on either celiac artery (CA), superior mesenteric artery (SMA), right renal artery (RRA), or left renal artery (LRA). Baseline demographic, clinical, and perioperative characteristics, as well as outcomes such as 30-day mortality, disease/treatment-related mortality, Major Adverse Cardiovascular Events(MACE: death, MI, stroke), overall complications, and reinterventions, were compared between the groups. Univariable and multivariable analysis was conducted.
RESULTS: 551 patients were involved in the final analysis, of which 386 (70.1%) underwent TEVAR without a VBV intervention, whereas 165 (29.9%) underwent TEVAR in association with intervention on at least one of the VBVs (CA, SMA, RRA, LRA). Baseline variables are presented in Figure 1. Patients who underwent TEVAR with a VBV intervention had statistically significantly lower rates of 30-day mortality (10.9% vs 17.9%, p=0.040), MACE (16.4% vs 24.6%, p=0.033), a tendency towards statistically significantly lower rates of disease/treatment-related mortality (8.5% vs 14.5%, p=0.052), and overall complications (42.2% vs 50.3%, p=0.092) (Figure 2). After adjustment of confounders, patients who underwent TEVAR with a VBV intervention had 55% decreased odds of 30-day mortality (OR: 0.45, 95%CI: 0.23-0.88, p=0.020), 61% decreased odds of disease/treatment-related mortality (OR: 0.39, 95%CI: 0.18-0.85, p=0.018), and a 45% decreased odds of MACE (OR: 0.55, 95%CI: 0.33-0.94, p=0.028). VBV intervention was also associated with a tendency towards statistically significantly lower odds of overall complications (OR: 0.69, 95%CI: 0.46-1.06, 0.091) (Figure 2).
CONCLUSIONS: In a real-world multi-institutional setting TEVAR with VBV intervention is associated with significantly reduced rates of 30-day mortality, disease/treatment-related mortality, and MACE, as well as a tendency towards statistically significantly lower rates of overall complications in TBAD patients presenting with visceral malperfusion. The role of TEVAR and adjunctive visceral branch intervention in the resolution of visceral malperfusion may need to be revised. A prospective study is required to confirm these findings.
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