Implications of secondary aortic intervention after thoracic endovascular aortic repair for acute and chronic type B dissection

Abstract

Background: Thoracic endovascular aortic repair (TEVAR) has become a mainstay of therapy for acute and chronic type B aortic dissection (TBAD). Dynamic aortic morphologic changes, untreated dissected aorta, and persistent false lumen perfusion have significant consequences for reintervention after TEVAR for TBAD. However, few reports contrast differences in secondary aortic intervention (SAI) after TEVAR for TBAD or describe their influence on mortality. This analysis examined incidence, timing, and types of SAI after TEVAR for acute and chronic TBAD and determined their impact on survival.Methods: All TEVAR procedures for acute and chronic TBAD (2005)(2006)(2007)(2008)(2009)(2010)(2011)(2012)(2013)(2014)(2015)(2016) were retrospectively reviewed. Patients with staged (<30 days) or concomitant ascending aortic arch repair or replacement were excluded. Acuity was defined by symptom onset (0-30 days, acute; >30 days, chronic). SAI procedures were grouped into open (intended treatment zone or remote aortic site), major endovascular (TEVAR extension or endograft implanted at noncontiguous site), and minor endovascular (side branch or false lumen embolization) categories. Kaplan-Meier methodology was used to estimate freedom from SAI and survival. Cox proportional hazards were used to identify SAI predictors.Results: TEVAR for TBAD was performed in 258 patients (acute, 49% [n ¼ 128]; chronic, 51% [n ¼ 130]). Mean follow-up was 17 6 22 months with an overall SAI rate of 27% (n ¼ 70; acute, 22% [28]; chronic, 32% [42]; odds ratio, 1.7; 95% confidence interval, 0.9-2.9; P ¼ .07]. Median time to SAI was significantly less after acute than after chronic dissection (0.7 [0-12] vs 7 [0-91] months; P < .001); however, freedom from SAI was not different (1-year: acute, 67% 6 4%, vs chronic, 68% 6 5%; 3-year: acute, 65% 6 7%, vs chronic, 52% 6 8%; P ¼ .7). Types of SAI were similar (acute vs chronic: open, 61% vs 55% [P ¼ .6]; major endovascular, 36% vs 38% [P ¼ .8]; minor endovascular, 21% vs 21% [P ¼ 1]). The open conversion rate (either partial or total endograft explantation: acute, 10% [13/128]; chronic, 15% [20/130]; P ¼ .2) and incidence of retrograde dissection (acute, 6% [7/128]; chronic, 4% [5/130]; P ¼ .5) were similar. There was no difference in survival for SAI patients (5-year: acute þ SAI, 55% 6 9%, vs acute without SAI, 67% 6 8% [P ¼ .3]; 5-year: chronic þ SAI, 72% 6 6%, vs chronic without SAI, 72% 6 7% [P ¼ .7]). Factors associated with SAI included younger age, acute dissection with larger maximal aortic diameter at presentation, Marfan syndrome, and use of arch vessel adjunctive procedures with the index TEVAR. Indication for the index TEVAR (aneurysm, malperfusion, rupture, and pain or hypertension) or remote preoperative history of proximal arch procedure was not predictive of SAI.Conclusions: SAI after TEVAR for TBAD is common. Acute TBAD has a higher proportion of early SAI; however, chronic TBAD appears to have ongoing risk of remediation after the first postoperative year. SAI types are similar between ...

Ten-Year Clinical Characteristics and Early Outcomes of Type B Aortic Dissection Patients With Thoracic Endovascular Aortic Repair

“…Chronic TBAD was found to have poorer aortic remodeling during follow-up. 39,40,41 Based on a large sample, our findings could raise further concern about the early postoperative complications of chronic patients. Eggebrecht et al found that more rigid intimal flaps and non-compliant aortic walls in chronic patients caused more fatal in-hospital complications after TEVAR, such as aorto-esophageal fistula.…”

Commentary: Another Issue for the Modern Vascular Specialist to Consider: Advanced Imaging Software

“…Looking at the big picture, long-term instability of aortic endografts, both abdominal and thoracic, remains a concern in up to one-fourth of cases. 3,5,6 Such issues make lifelong surveillance mandatory, a point that has become more important since the management trends for aortic pathologies have expanded the treatment to younger patients with longer life expectancies, in addition to octo-and nonagenarians. 1 The complexity of thoracic aortic diseases, their inaccessibility to ultrasound examination, and the extreme variability of postoperative complications compel us to submit our patients to CTA or magnetic resonance angiography at 30 days, 6 months, and then yearly for the rest of their lives.…”

“…Such feelings are more frequent after we treat aortic patients presenting with short, tortuous, and calcified necks, basically those patients who are totally outside the instructions for use and who may represent up to 80% of our patient volume. 1-3…”

“…Looking at the big picture, long-term instability of aortic endografts, both abdominal and thoracic, remains a concern in up to one-fourth of cases. 3,5,6 Such issues make lifelong surveillance mandatory, a point that has become more important since the management trends for aortic pathologies have expanded the treatment to younger patients with longer life expectancies, in addition to octo- and nonagenarians. 1…”

“…Such feelings are more frequent after we treat aortic patients presenting with short, tortuous, and calcified necks, basically those patients who are totally outside the instructions for use and who may represent up to 80% of our patient volume. [1][2][3] Currently, imaging software is widely available to drill down the CTA scans and to determine apposition surface in the proximal and distal landing zones, apposition of the endograft fabric with the aortic wall, shortest apposition length, endograft inflow and outflow diameters, and distances between fabric extremes and anatomical landmarks. In addition, these tools allow us to define the stability of endograft position, supporting our practice by offering an essential diagnostic aid in endovascular aortic repair surveillance.…”