Health Insurance Payor Type as a Predictor of Clinical Presentation and Mortality in Patients Undergoing Urgent or Emergent TEVAR for Type B Aortic Dissection: Insights from Society for Vascular Surgery Vascular Quality Initiative Database.

Race-based outcomes of thoracic aortic aneurysms and dissections in the Global Registry for Endovascular Aortic Treatment

Type B aortic dissection (TBAD) is rare in patients aged ≤30 years, and data on this population remain limited. This study aimed to characterize the underlying aetiology, and outcomes of invasively treated young patients with TBAD, with a focus on the impact of heritable thoracic aortic disease (HTAD). A retrospective multicentre analysis was conducted across 19 international aortic centres, including 139 patients aged ≤30 years with TBAD. Patients with chronic TBAD (n = 42) were excluded for the final analysis. The cohort was classified as uncomplicated (n = 86) or complicated (n = 53) TBAD. Clinical, radiologic, intraoperative, and postoperative data were collected using standardized forms. Outcomes were compared between subgroups defined by TBAD complexity, HTAD status, and surgical strategy. Kaplan-Meier and Andersen-Gill analyses were used for survival and recurrent aortic intervention, respectively. Mean follow-up time was 6.5 years. HTAD was identified in 57% of patients. Most presented with uncomplicated TBAD (62%), while high-risk uncomplicated cases were uncommon. Endovascular repair was predominant in complicated TBAD, while open repair was more frequent in uncomplicated cases. Early mortality was low (n = 3), and mid-term survival was excellent across all subgroups. HTAD was a significant predictor of recurrent aortic interventions (HR = 3.3, P = .004). No significant differences were observed in survival or reintervention rates between uncomplicated and complicated TBAD or between operative strategies. In young patients, TBAD predominantly occurs in the context of HTAD. Both open and endovascular repair are associated with excellent early outcomes and mid-term survival. However, HTAD remains a significant predictor of recurrent aortic interventions.

Thoracic Endovascular Aortic Repair on Zone 2 Landing for Type B Aortic Dissection

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Stanford type B aortic dissection (TBAD) is a life-threatening disease. Current therapeutic guidelines recommend medical therapy with aggressive blood pressure lowering for patients with acute TBAD unless they have fatal complications. Although patients with uncomplicated TBAD have relatively low early mortality, aorta-related adverse events during the chronic phase worsen the long-term clinical outcome. Recent advances in thoracic endovascular aortic repair (TEVAR) can improve clinical outcomes in patients with both complicated and uncomplicated TBAD. According to present guidelines, complicated TBAD patients are recommended for TEVAR. However, the indication in uncomplicated TBAD remains controversial. Recent results of randomized trials, which compared the clinical outcome in patients treated with optimal medical therapy and those treated with TEVAR, suggest that preemptive TEVAR should be considered in uncomplicated TBAD with suitable aortic anatomy. However, these trials failed to show improvement in early mortality in patients treated with TEVAR compared with patients treated with optimal medical therapy, which suggest the importance of patient selection for TEVAR. Several clinical and imaging-related risk factors have been shown to be associated with early disease progression. Preemptive TEVAR might be beneficial and should be considered for high-risk patients with uncomplicated TBAD. However, an interdisciplinary consensus has not been established for the definition of patients at high-risk of TBAD, and it should be confirmed by experts including physicians, radiologists, interventionalists, and vascular surgeons. This review summarizes the current understanding of the therapeutic strategy in patients with TBAD based on evidence and expert consensus.

Effect of Thoracic Endovascular Aortic Repair on Aortic Remodeling in Patients with Type B Aortic Dissection in an Asian Population

Ethnic & Sex Disparities in Type B Aortic Dissection Patients Undergoing Thoracic Endovascular Aortic Repair: An International Perspective

Evolving Experience of Percutaneous Management of Type B Aortic Dissection

Uncomplicated type B aortic dissection (unTBAD) comprises the estimated majority of type B aortic dissection (TBAD), presenting without any of the complications associated with complicated TBAD (coTBAD). Although first-line treatment for coTBAD is thoracic endovascular aortic repair (TEVAR), and despite the fact that TEVAR has proven its safety and effectiveness in the treatment of unTBAD, unTBAD is still being predominantly managed conservatively with medical therapy, with a small proportion of patients being offered TEVAR. The main scope of this review is to highlight the evidence in the literature of the demographic characteristics and associated co-morbidities of unTBAD patients undergoing TEVAR in order to produce a risk stratification system to achieve favourable outcomes. A comprehensive literature search was conducted using multiple electronic databases including PubMed, Ovid, Scopus, and EMBASE. Multiple demographic characteristics and associated co-morbidities of unTBAD patients affecting TEVAR outcomes were identified, assessed, and investigated, including age, gender, race, genetics, medical conditions, such as hypertension and diabetes, and lifestyle factors such as smoking. Most factors were associated with increased risks of mortality and morbidity, while others, such as race, were identified as being protective against those when it comes to TEVAR. Despite the favourable results yielded by TEVAR in unTBAD, there remains a grey area concerning its management. Thus, it is important to incorporate the demographics and co-morbidities of unTBAD patients' when into clinical judgement when assessing indications for TEVAR intervention to ensure optimum results can be achieved.

There are many publications dealing with treatment options for uncomplicated type B aortic dissection (TBAD). Early TEVAR (Thoracic Endovascular Aortic Repair) may improve aortic-specific survival and delay disease progression in the long-term. Especially in patients with uncomplicated TBAD and additional high-risk features, preemptive TEVAR may improve late outcomes.We conducted a retrospective analysis of all patients treated for TBAD in our hospital between February 2017 and September 2021. Comorbidities, intraoperative data, 30-day mortality and postprocedural complications were analysed.During the above-mentioned period, 61 patients (38 males, median age 63 years) with TBAD were treated. Six patients received best medical treatment (BMT). 55 patients were treated by TEVAR and BMT. 11 patients (20%) had complicated TBAD, 12 patients (22%) had uncomplicated TBAD with high-risk features and 32 patients (58%) had uncomplicated TBAD. Technical success was 100%. No patient with uncomplicated TBAD died within the first 30 postoperative days. One patient with uncomplicated TBAD had a stroke after TEVAR. Two reinterventions were performed on day 7 and day 9 after TEVAR.Patients with uncomplicated TBAD could be treated by early TEVAR, with a low rate of perioperative complications. In patients with uncomplicated TEVAR and high-risk features, early TEVAR with BMT should be considered as the treatment of choice.

BackgroundCoverage of the left subclavian artery (LSA) during thoracic endovascular aortic repair (TEVAR) for type B aortic dissection (TBAD) increases the risk of major adverse events (MAEs). In situ laser‐assisted fenestration allows for LSA revascularization in both elective and urgent settings, yet its safety and efficacy lack robust multicenter data.MethodsLLTEVAR (LSA Revascularization With Laser‐Assisted Fenestration During TEVAR) was a prospective, single‐arm, multicenter study that enrolled patients with acute complicated or high‐risk acute TBAD. The primary safety end point was freedom from composite MAEs (mortality, stroke, myocardial infarction, paraplegia, type Ia endoleak, and retrograde aortic dissection/intramural hematoma) within 30 days after the procedure. Univariate and multivariable analyses identified risk factors for composite MAEs.ResultsA total of 100 patients (mean age, 60.5±12.6 years) were enrolled at 5 vascular centers between July 2018 and September 2021. The technical success rate of LSA fenestration was 98.0% (98/100). The 30‐day primary safety end point was 86.0%. Complicated TBAD (OR, 4.04; 95% CI, 1.05–15.59; P=0.04) and type II/III aortic arch (OR, 4.61; 95% CI, 1.18–17.95; P=0.03) were significantly associated with a higher risk of composite MAEs within 30 days.ConclusionIn situ laser‐assisted fenestration for LSA revascularization during TEVAR demonstrates favorable procedural success and acceptable short‐term outcomes in patients with acute TBAD. However, periprocedural MAEs remain a critical consideration, particularly in those with complicated TBAD with type II/III aortic arch anatomy. Further studies with comparative groups and long‐term follow‐up are warranted to validate these outcomes.RegistrationURL: https://clinicaltrials.gov; Unique Identifier: NCT03845829.

New-onset antegrade Stanford type B aortic dissection (TBAD) after endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) is rare. The extension of aortic dissection leads to various symptoms and affects the stent graft. Moreover, various symptoms may arise owing to a stent graft being present. We describe 2 cases of complicated acute TBAD occurring after EVAR, which were ultimately fatal. The case in which rupture occurred could not be treated and the patient died. In another case with bilateral lower extremity malperfusion caused by collapse and occlusion of the endograft, extra-anatomical bypass was performed. Although the collapsed endograft gradually re-expanded, the patient ultimately died because of multiorgan failure. We have reviewed the literature and analyzed the treatment of complicated TBAD after EVAR.

Acute Type B aortic dissection (TBAD) can cause organ malperfusion, e.g., lower limb ischemia (LLI). Thoracic endovascular aortic repair (TEVAR) represents the standard treatment for complicated TBAD; however, with respect to LLI, data is scant. The aim of this study was to investigate clinical and morphological outcomes in patients with complicated TBAD and LLI managed with a “TEVAR-first” policy. Between March 1997 and December 2021, 731 TEVAR-procedures were performed, including 106 TBAD-cases. Cases with TBAD + LLI were included in this retrospective analysis. Study endpoints were morphological/clinical success of TEVAR, regarding aortic and extremity-related outcome, including extremity-related adjunct procedures (erAP) during a median FU of 28.68 months. A total of 20/106 TBAD-cases (18.8%, 32–82 years, 7 women) presented with acute LLI (12/20 Rutherford class IIb/III). In 15/20 cases, true lumen-collapse (TLC) was present below the aortic bifurcation. In 16/20 cases, TEVAR alone resolved LLI. In the remaining four cases, erAP was necessary. A morphological analysis showed a relation between lower starting point and lesser extent of TLC and TEVAR success. No extremity-related reinterventions and only one major amputation was needed. The data strongly suggest that aTEVAR-first-strategy for treating TBAD with LLI is reasonable. Morphological parameters might be of importance to anticipate the failure of TEVAR alone.

Outcomes of Hybrid Technique for Type B Aortic Dissection Involving Distal Aortic Arch

Purpose: Hybrid thoracic endovascular aortic repair (TEVAR) for aortic arch aneurysms is a minimally invasive procedure with improved results. This study aimed to clarify the effectiveness and expand the possibilities of zone 1 and 2 landing TEVAR for type B aortic dissection (TBAD) using our treatment strategy. Methods: This retrospective, single-center, observational cohort study included 213 patients (TBAD, n=69; thoracic arch aneurysm [TAA], n=144; median age, 72 years; median follow-up period, 6 years) from May 2008 to February 2020. The following conditions were satisfied before performing zone 1 and 2 landing TEVAR: TBAD; proximal landing zone (LZ): diameter <37 mm, length >15 mm, and nondissection area, proximal stent-graft: size ≤40 mm and oversizing rate: 10% to 20%, and TAA; proximal LZ: diameter ≤42 mm and length >15 mm, proximal stent-graft: size ≤46 mm and oversizing rate: 10% to 20%. Of the 69 patients in the TBAD group, 34 (49.3%) had patent false lumen (PFL), and 35 (50.7%) had false lumen partial thrombosis (FLPT), including ulcer-like projections. Emergency procedures were performed in 33 (15.5%) patients. Results: There were no significant differences in the in-hospital mortality (TBAD: 1.5% vs TAA: 0.7%, p=0.544) or the in-hospital aortic complications (TBAD: n=1 vs TAA: n=5, p=0.666). Retrograde type A dissection was not observed in the TBAD group. The aortic event-free rates at 10 years were 89.7% (95% confidence interval [CI]: 78.7%–95.3%) and 87.9% (95% CI: 80.3%–92.8%) in the TBAD and TAA groups, respectively (log-rank p=0.636). In the TBAD group, the early and late outcomes were not significantly different between the PFL and FLPT groups. Conclusion: Satisfactory early and long-term results were obtained with zone 1 and 2 landing TEVAR. The TBAD cases had the same good results as the TAA cases. Using our strategy, we especially might reduce complications and be an effective treatment for acute complicated TBAD. Clinical Impact This study aimed to clarify the effectiveness and expand the possibilities of zones 1 and 2 landing TEVAR for type B aortic dissection (TBAD) using our treatment strategy. Satisfactory early and long-term results in the TBAD and thoracic arch aneurysm (TAA) groups were obtained with zones 1 and 2 landing TEVAR. The TBAD cases had the same good results as the TAA cases. Using our strategy, we especially might reduce complications and be an effective treatment for acute complicated TBAD.