Long-Term Outcome of Aortic Dissection With Patent False Lumen

Abstract

Background— Patent false lumen in aortic dissection has been associated with poor prognosis. We aimed to assess the natural evolution of this condition and predictive factors. Methods and Results— One hundred eighty-four consecutive patients, 108 surgically treated type A and 76 medically treated type B, were discharged after an acute aortic dissection with patent false lumen. Transesophageal echocardiography was performed before discharge, and computed tomography was performed at 3 months and yearly thereafter. Median follow-up was 6.42 years (quartile 1 to quartile 3: 3.31–10.49). Forty-nine patients died during follow-up (22 type A, 27 type B), 31 suddenly. Surgical or endovascular treatment was indicated in 10 type A and 25 type B cases. Survival free from sudden death and surgical-endovascular treatment was 0.90, 0.81, and 0.46 (95% CI, 0.36–0.55) at 3, 5, and 10 years, respectively. Multivariate analysis identified baseline maximum descending aorta diameter (hazard ratio [HR]: 1.32 [1.10–1.59]; P =0.003), proximal location (HR: 1.84 [1.06–3.19]; P =0.03), and entry tear size (HR: 1.13 [1.08–1.2]; P <0.001) as predictors of dissection-related adverse events, whereas mortality was predicted by baseline maximum descending aorta diameter (HR: 1.36 [1.08–1.70]; P =0.008), entry tear size (HR: 1.1 [1.04–1.16]; P =0.001), and Marfan syndrome (HR: 3.66 [1.65–8.13]; P =0.001). Conclusions— Aortic dissection with persistent patent false lumen carries a high risk of complications. In addition to Marfan syndrome and aorta diameter, a large entry tear located in the proximal part of the dissection identifies a high-risk subgroup of patients who may benefit from earlier and more aggressive therapy.

Editor's Choice – Management of Descending Thoracic Aorta Diseases

“…98 In general, chronic type B aortic dissection (CTBAD) also includes patients with a residual TBAD after repair of a type A dissection (De Bakey type I dissection). 168 Aortic related complications may occur in 20e50% of patients with CTBAD. 169 Overall, it is estimated that approximately 20e40% of patients with CTBAD develop enlargement of the FL that warrants treatment and approximately 25% of DTAA or TAAA are associated with AD.…”

“…169 In addition, the presence of an entry tear larger than 10 mm in diameter or located in the arch or proximal DTA has been recognized as a predictor of late mortality and the consequent need for aortic repair. 168 Moreover, in patients treated for type A dissection with a patent distal FL, a large area of the FL (>70% of the total aortic area) is considered to be a predictor of aneurysmal degeneration. 202 Conversely, FL thrombosis has been associated with a slower growth rate.…”

“…These surveillance intervals are based on several reported experiences, as no definitive evidence exists. 44,65,85,88,107,108,129,168,173,299 All patients with DTA disease require aggressive management of hypertension, secondary prevention of cardiovascular diseases, and close follow up to monitor the evolution of the diseased aorta. In particular, conservatively treated patients are prone to develop progression of disease 195 and OR patients can develop anastomotic pseudoaneurysm, new para-anastomotic aneurysms, graft infection or graft occlusion.…”

“…173 In ATBAD, some predictors of aortic growth, like the entry tear size and partial FL thrombosis, are now identified. 168,174 Patients with chronic TBAD may develop progression of the initial dissection or a secondary aortic dissection event like intramural haematoma. In addition, in ATBAD patients treated with TEVAR, distal perfusion of the FL is often observed, and its role remains poorly understood.…”

Descending endograft for DeBakey type 1 aortic dissection: pro

“…In particular, a DTA diameter at initial presentation >35 mm was found to be a risk factor for a patent false lumen postoperatively (24); an initial false lumen diameter ≥22 mm was associated with accelerated aortic dilatation and occurrence of adverse aortic events (37), and a large proximal intimal tear (>10 mm) emerged as risk factor for dissection related events and mortality (38). Moreover, Marfan syndrome or other connective tissue diseases are well-known risk factors for distal aortic reintervention (3,38). The use of stent-grafts in Marfan patients is controversial mostly due to the young age of these patients, the limited long-term data available for the endovascular procedures and the increased risk of stentrelated degeneration of the weakened Marfan aortic wall.…”