Acute Type B Dissection: Intervention for Rupture or Impending Rupture

Abstract

Objective: Operative procedures for acute type B aortic dissection (ABAD) are usually performed in the setting of complications. This study focuses on outcomes for repair of ABAD for indications of rupture or impending rupture. Methods: Of the 383 patients admitted with ABAD (1995-2010), 41 (10.7%) underwent open (DTAR, 18) or endovascular aortic repair (TEVAR, 23) for rupture or impending rupture at a median of 3.5 days following presentation. Indications for intervention included rupture (17) or factors portending rupture including rapid expansion (11), uncontrolled pain (13), aortic size >5.0 cm (13) or refractory hypertension (2). 11 patients had multiple indications. Isolated intramural hematoma was present in 10. Extent of repair included arch (32, 78%) or total descending aorta (16, 39%). Selection of therapy was based upon age and extent of comorbidities. TEVAR, though available since 1993, was preferentially used since 2007. Patients undergoing TEVAR were older and more frequently had prior MI, renal failure, tobacco use history, or Debakey IIIA ABAD (all P < .05). Results: 30-day mortality was 17% (n = 7). Morbidity included stroke (3), renal failure needing dialysis (3), or permanent paraplegia (3). Independent correlates of a composite outcome of mortality and these morbidities included presentation with rupture (P = .02, OR 7.6) or active tobacco use (P = .02, OR 9.8), but not treatment strategy (P = .18). 8 yr Kaplan-Meier survival was 49.4%. Independent predictors of late mortality included occurrence of perioperative stroke or presentation with aortic rupture during late follow-up (both P < .002). 8 yr freedom from aortic rupture or reintervention was 76.6%. When compared to open repair, TEVAR had a similar late survival (3 yr 67.1% vs. DTAR 72.2%, log rank P = .8), and rate of false lumen thrombosis (P = .56). 3 yr freedom from aortic reintervention or rupture was higher after open repair (DTAR 94% vs. TEVAR 61%, log rank P = .16). Conclusion: Intervention for acute type B dissection complicated by rupture or impending rupture remains associated with significant rates of early and late morbidity and reintervention. Understanding the baseline differences in the treatment groups presented in this study, these data support the use of an endovascular approach for this indication in acute dissection.