Favorable Impact of Thoracic Endovascular Aortic Repair on Long-Term Survival in Patients With Acute Uncomplicated Type B Aortic Dissection

Abstract

Standard nonoperative medical therapy for uncomplicated type B dissection has been questioned by recent studies demonstrating improved outcomes in those treated with thoracic endovascular aortic repair (TEVAR). This study assessed long-term survival after acute uncomplicated type B dissection comparing medical therapy (MED), open repair (OPEN), and TEVAR. The California Office of Statewide Hospital Planning Development database was analyzed from 2000 to 2010. Patients with emergent admission for aortic dissection were identified, and those with type A dissection, trauma, bowel ischemia, lower extremity ischemia, acidosis, or shock were excluded. The cohort was stratified by treatment type at index admission into MED, OPEN, and TEVAR. Bivariate, multivariable, and survival analyses were used to evaluate the impact of treatment type on long-term overall survival. There were 9165 uncomplicated type B dissections admitted, of which 95% were MED, 2.0% OPEN, and 2.9% TEVAR. Mean age was 66 ± 15 years, with 39% female, 2.4% cocaine users, 18% with congestive heart failure, and 17% with a Charlson comorbidity score >3. Mean length of stay was 6.7 ± 8.9 days in MED, 15 ± 15 days in OPEN, and 12 ± 10 days in TEVAR (P < .001); mean inpatient costs were $57,000 MED, $200,000 OPEN, and $130,000 TEVAR (P < .001). Overall inpatient mortality was 6.5%, 6.3% for MED, 14% for OPEN, and 7.1% for TEVAR (P < .001). Overall 30-day, 1-year, and 5-year survival rates were 86% ± 0.4%, 76% ± 0.4%, and 60% ± 0.6%; in MED, they were 86% ± 0.4%, 84% ± 2%, and 60% ± 0.6%; in OPEN, they were 83% ± 3%, 76% ± 0.5%, and 67% ± 4%; and in TEVAR, they were 93% ± 2%, 85% ± 2%, and 76% ± 4% respectively (Fig; log-rank, P < .01). On risk-adjusted multivariable analysis, TEVAR improved survival (hazard ratio, 0.68 [95% confidence interval, 0.55-0.83]; P < .01) compared with MED. This study assessing statewide survival after acute uncomplicated type B dissections shows an independent survival advantage for TEVAR over the long-standing practice of medical therapy. These data add further evidence for a paradigm shift in acute management of type B dissection and support initiation of randomized controlled trials of TEVAR for acute uncomplicated type B dissections.