Comparison of mid-term outcomes of endovascular repair and medical management in patients with acute uncomplicated type B aortic dissection

Abstract

Objectives: To further assess the early and mid-term outcomes of thoracic endovascular aortic repair (TEVAR) in patients with acute uncomplicated type B aortic dissection (TBAD) compared with those receiving best medical treatment (BMT). Methods: Between February 2008 and March 2018, 357 consecutive patients with acute uncomplicated TBAD were retrospectively analyzed. Among them, 191 patients underwent TEVAR, and 166 received BMT. After propensity score matching, we obtained 145 matched pairs for analysis. Results: In the matched population, the 30-day mortality between the TEVAR group and the BMT group showed no statistically significant difference, whereas the early adverse events rates in the TEVAR group were significantly greater than that of the BMT group (P ¼ .003). Freedom from all-cause mortality in the TEVAR group was significantly greater than that of the BMT group (TEVAR: 91.9% at 5 years, BMT: 82.2% at 5 years, P ¼ .028). Freedom from aortic-related mortality in the TEVAR group was significantly greater than that of the BMT group (TEVAR: 94.1% at 5 years, BMT: 86.1% at 5 years, P ¼ .044). Multivariable Cox-hazard regression analysis demonstrated that the older age (hazard ratio [HR], 1.04; 95% confidence interval [CI], 1.01-1.08, P ¼ .013), BMT (HR, 2.33; 95% CI, 1.08-5.05, P ¼ .032), and the distance between the primary entry tear and the left subclavian artery<2.0 cm (HR, 2.30; 95% CI, 1.06-4.99, P ¼ .035) were the significant risk factors for all-cause death. Given death as a competing factor, the cumulative incidence of rupture in the BMT group was significantly greater than that of the TEVAR group (BMT: 13.7% at 5 years, TEVAR: 5.1% at 5 years, P ¼ .024). Conclusions: Despite more complications in the early stage, TEVAR was associated with decreased risk of late death and had fewer late aortic ruptures compared with BMT in patients with acute uncomplicated TBAD. Therefore, TEVAR may be considered as the first option to improve the late outcomes in these patients.

Commentary: Management of acute uncomplicated type B aortic dissection: In medio stat virtus

“…The authors had the ambitious idea to compare in a retrospective analysis the use of TEVAR (n ¼ 191) versus medical treatment (n ¼ 166) in patients with acute uncomplicated type B AD. As expected also from literature, 4 patients receiving TEVAR had greater early 30-day mortality, although not statistically significant. However, those receiving best medical treatment had 3 times the risk (13.7% vs 5.1% at 5 years) of late adverse events (rupture and aortic enlargement) and reintervention compared with endovascular repair.…”

Elevated Preoperative Neutrophil-to-lymphocyte Ratio Predicts Early Adverse Outcomes in Uncomplicated Type B Aortic Dissection Undergoing TEVAR

“…Although long-term safety and e cacy of TEVAR have been con rmed with multiple studies, 3,5,16 early adverse events still attract controversy and impede the extensive application of TEVAR in uTBAD. In 2019, Professor Adams and his colleagues 6 suggested that high-risk subgroup of uTBAD patients may bene t from early intervention.…”

“…4 Clinical researches based on retrospective cohort suggest that TEVAR is bene cial in longterm outcomes for uTBAD. 3,5 However, there are still debates about timing and indications of TEVAR on uTBAD because of disappointing early outcomes compared with optimal medical treatment. 6 Recently, there has been a signi cant body of work which has investigated the use of systemic in ammatory marker neutrophil-tolymphocyte ratio (NLR) to both prognosticate patients and to guide treatment.…”

Updates on Indications for TEVAR in Type B Aortic Dissection

“…The TEVAR group had more adverse events compared to best medical therapy in the early stage (11.7% vs 2.8%, P = 0.003), although type 1 endoleak associated with TEVAR was the most significant contributor. 41 Together, the available data suggest that uncomplicated patients with high-risk features derive the most benefit from early TEVAR. Intervention performed in the subacute phase allows for acceptable positive remodeling while mitigating the periprocedural risks associated with early intervention.…”

“…Recent evidence, however, raises the question of whether intervention should be more aggressively pursued within the acute phase window in order to maximize aortic remodeling benefit. 35,[39][40][41]…”