Key success factors for thoracic endovascular aortic repair for non-acute Stanford type B aortic dissection

Kitamura, Tadashi; Torii, Shinzo; Oka, Norihiko; Horai, Tetsuya; Nakashima, Kouki; Koyama, Shingo; Hari, Yosuke; Araki, Haruna; Sato, Hajime; Miyaji, Kagami

doi:10.1093/ejcts/ezu012

Cited by 27 publications

(23 citation statements)

References 24 publications

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“…For TEVAR, elective interventions ranged between 62.5% and 100.0% [ 21 , 28 , 38 , 45 , 46 , 52 ], urgent operations between 18.8% and 97.2% [ 21 , 28 , 41 ], and emergency procedures were performed between 2.0% and 18.8% [ 21 , 28 , 41 , 43 , 45 , 46 , 49 , 51 , 52 ]. Reported time intervals from incident dissection to TEVAR ranged between a median of 3 weeks up to 36.0 months [ 21 , 34 , 36 , 44 , 46 ] and a mean of 3 weeks and 53.8 months [ 29 , 33 , 37 , 38 , 40 , 43 , 45 , 49 , 50 ]. Mean time to intervention was 24.4 months.…”

Section: Resultsmentioning

confidence: 99%

“…Mean time to intervention was 24.4 months. Indications for TEVAR were aortic aneurysm (74.5% to 100.0%) [ 28 , 32 , 35 , 37 , 43 , 45 , 48 , 49 ], failure of OMT (12.3%) [ 32 ], rupture (2.7% to 10.0%) [ 32 , 35 , 41 , 43 , 46 , 49 ], rapid aortic enlargement (11.8% to 100.0%) [ 28 , 37 , 41 , 43 , 49 ], recurrent/refractory pain (4.3% to 57.7%) [ 32 , 37 , 41 , 43 , 49 ], malperfusion (2.5% to 18.8%) [ 32 , 41 , 46 , 49 ], patent false lumen (FL) (64.2%) [ 40 ] and other indications (6.6% to 23.5%) [ 37 , 40 , 49 ]. Double indications could be present in a single patient.…”

Section: Resultsmentioning

confidence: 99%

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Contemporary Management Strategies for Chronic Type B Aortic Dissections: A Systematic Review

et al. 2016

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BackgroundCurrently, the optimal management strategy for chronic type B aortic dissections (CBAD) is unknown. Therefore, we systematically reviewed the literature to compare results of open surgical repair (OSR), standard thoracic endovascular aortic repair (TEVAR) or branched and fenestrated TEVAR (BEVAR/FEVAR) for CBAD.MethodsEMBASE and MEDLINE databases were searched for eligible studies between January 2000 and October 2015. Studies describing outcomes of OSR, TEVAR, B/FEVAR, or all, for CBAD patients initially treated with medical therapy, were included. Primary endpoints were early mortality, and one-year and five-year survival. Secondary endpoints included occurrence of complications. Furthermore, a Time until Treatment Equipoise (TUTE) graph was constructed.ResultsThirty-five articles were selected for systematic review. A total of 1081 OSR patients, 1397 TEVAR patients and 61 B/FEVAR patients were identified. Early mortality ranged from 5.6% to 21.0% for OSR, 0.0% to 13.7% for TEVAR, and 0.0% to 9.7% for B/FEVAR. For OSR, one-year and five-year survival ranged 72.0%-92.0% and 53.0%-86.7%, respectively. For TEVAR, one-year survival was 82.9%-100.0% and five-year survival 70.0%-88.9%. For B/FEVAR only one-year survival was available, ranging between 76.4% and 100.0%. Most common postoperative complications included stroke (OSR 0.0%-13.3%, TEVAR 0.0%-11.8%), spinal cord ischemia (OSR 0.0%-16.4%, TEVAR 0.0%-12.5%, B/FEVAR 0.0%-12.9%) and acute renal failure (OSR 0.0%-33.3%, TEVAR 0.0%-34.4%, B/FEVAR 0.0%-3.2%). Most common long-term complications after OSR included aneurysm formation (5.8%-20.0%) and new type A dissection (1.7–2.2%). Early complications after TEVAR included retrograde dissection (0.0%-7.1%), malperfusion (1.3%–9.4%), cardiac complications (0.0%–5.9%) and rupture (0.5%–5.0%). Most common long-term complications after TEVAR were rupture (0.5%–7.1%), endoleaks (0.0%–15.8%) and cardiac complications (5.9%-7.1%). No short-term aortic rupture or malperfusion was observed after B/FEVAR. Long-term complications included malperfusion (6.5%) and endoleaks (0.0%-66.7%). Reintervention rates after OSR, TEVAR and B/FEVAR were 5.8%-29.0%, 4.3%-47.4% and 0.0%-53.3%, respectively. TUTE for OSR was 2.7 years, for TEVAR 9.9 months and for B/FEVAR 10.3 months.ConclusionWe found a limited early survival benefit of standard TEVAR over OSR for CBAD. Complication rates after TEVAR are higher, but complications after OSR are usually more serious. Initial experiences with B/FEVAR show its feasibility, but long-term results are needed to compare it to OSR and standard TEVAR. We conclude that optimal treatment of CBAD remains debatable and merits a patient specific decision. TUTE seems a feasible and useful tool to better understand management outcomes of CBAD.

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Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Contemporary Management Strategies for Chronic Type B Aortic Dissections: A Systematic Review

et al. 2016

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“…In addition, Tsai et al [66] showed that a proximal location of the entry tear may cause aortic expansion. In the series by Kitamura et al [67], the primary entry at the outer curvature of the distal aortic arch was associated with a lower chance of thrombosis of the descending false lumen, and a primary entry at the inner curvature of the distal aortic arch was associated with a higher risk of complication in acute TBAD [33,68].…”

Section: Entry Tearmentioning

confidence: 92%

Type B Aortic Dissection: A Review of Prognostic Factors and Meta-analysis of Treatment Options

Luebke

Brunkwall

2014

aorta

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According to international guidelines, stable patients with uncomplicated Type B aortic dissection (TBAD) should receive optimal medical treatment. Despite adequate antihypertensive therapy, the long-term prognosis of these patients is characterized by a significant aortic aneurysm formation in 25-30% within four years, and survival rates from 50 to 80% at five years and 30 to 60% at 10 years. In a prospective randomized trial, preemptive thoracic endovascular aortic repair (TEVAR) in patients with chronic uncomplicated TBAD was associated with an excess early mortality (due to periprocedural hazards), but the procedure showed its benefit in prevention of aortic-specific mortality at five years of follow-up. However, preemptive TEVAR may not be the treatment of choice in all patients with uncomplicated TBAD because of the inherent periprocedural complications like stroke, paraparesis, and death, as well as stent graft-induced complications (i.e., retrograde dissection or endoleaks). Thus, the TEVAR-related deaths and complications (especially paraplegia and stroke) raise concerns that moderate the better survival with TEVAR at five years. By timely identification of those patients prone for developing complications, early intervention, preferably in the subacute or early chronic phase, may improve the overall long-term outcome for these patients. Therefore, early detectable and reliable prognostic factors for adverse events are essential to stratify patients who can be treated medically and those who will benefit from rigorous follow-up and, in the long-term, from timely, or even prophylactic, TEVAR. Several studies have identified prognostic factors in TBAD such as aortic diameter, partial false lumen thrombosis, false lumen thickness, and location of the primary entry tear. Combining these clinical and radiological predictors may be essential to implement a patient-specific approach designed to intervene only in those patients who are at high risk of developing complications to improve the longterm outcomes of patients with uncomplicated Type B aortic dissection.

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“…These may include an aortic diameter of > 44 mm at diagnosis, partial false lumen thrombosis, false lumen diameter of > 22 mm (100% sensitive, 76% specific), location of primary entry tear on the under surface of the arch or on its medial aspect, width of entry tear > 10 mm, elliptical shape of true lumen, circular false lumen, crosssectional area of false lumen to true lumen of > 0.7, and a spiral configuration of the dissection (►Table 3). [32][33][34][35][36][37] Dissection is classified as complicated (►Table 4) if it is associated with refractory pain; malperfusion; rupture, free, or contained; hypertension that is associated with malperfusion or persistent despite full medical therapy; increase in periaortic hematoma; and hemorrhagic pleural effusion in two CT examinations, suggesting an impending rupture. 38,39 Moreover, refractory pain and persistent hypertension are associated with an increased mortality.…”

Section: Treatmentmentioning

confidence: 99%

Expanding Role of Endovascular Repair for Type B Aortic Dissection

Sharma

2017

J Clin Interv Radiol ISVIR

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Aortic dissection is a medical emergency that can quickly lead to death, despite optimal treatment. The Stanford classification is widely used and is in close relationship to clinical practice, as type A dissections require primary surgical repair whereas type B dissections are treated medically as initial treatment with surgery or endovascular repair (EVR) reserved for any complications. Multislice CT is the investigation of choice to establish the diagnosis and plan treatment strategies. Therapeutic strategies differ for treatment of an acute dissection compared with a chronic dissection. Traditionally, most institutions favor a “complication specific” approach for type B dissection with antihypertensive treatment and use of β-blockers as primary therapy. Surgery or EVR is reserved for patients with recurrent pain, life-threatening complications, or rapid aortic expansion. With above algorithms, there is evidence that 30 to 50% patients on conservative therapy develop serious morbidity or mortality over 5-year period. Clinical and imaging markers of adverse outcome are being identified to revise the management strategies and offer EVR to those at risk for adverse outcome. This is especially relevant in view of the fact that EVR for type B dissection is associated with procedural success in 99.2 ± 0.1% patients. Overall survival rates of 96.9% at 30 days, 96.7% at 6 months, 96.4% at 1 year, 95.6% at 2 years, and 95.2% at 5 years are reported after EVR in type B dissections. There is emerging evidence that EVR may be noninferior to surgery in this group of patients. These observations along with the development of dissection-specific device designs have the potential to rewrite the management algorithms for type B aortic dissection and define the role of EVR in this disease.

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Key success factors for thoracic endovascular aortic repair for non-acute Stanford type B aortic dissection

Cited by 27 publications

References 24 publications

Contemporary Management Strategies for Chronic Type B Aortic Dissections: A Systematic Review

Contemporary Management Strategies for Chronic Type B Aortic Dissections: A Systematic Review

Type B Aortic Dissection: A Review of Prognostic Factors and Meta-analysis of Treatment Options

Expanding Role of Endovascular Repair for Type B Aortic Dissection

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