Abstract
Thoracic endovascular aortic repair (TEVAR) has been selectively used for uncomplicated acute type B aortic dissection (TBAD); however, not all cases will benefit from TEVAR. A search for high risk clinical and radiographic predictors for complications is ongoing. This systematic review and meta-analysis aimed to identify predictors of major adverse events during follow-up of uncomplicated TBAD, in order to identify who might benefit from elective TEVAR. A systematic review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-analysis (PRISMA) Statement. 16 studies were included in a qualitative synthesis and 10 in the meta-analysis. Several risk factors associated to major adverse events have been described, including: 1) aortic diameter ≥40 mm; 2) greater false lumen diameter (>22 mm); 3) patent false lumen; 4) primary entry tear >10 mm; and 5) greater number of false lumen vessels origin. Quantitative synthesis identified an aortic diameter ≥40 mm significantly associated with major adverse events (HR=3.56; P<0.00001). Reporting of false lumen status, aortic diameters and growth, and demographic data was not always congruent with the most recent recommendations by Society for Vascular Surgery and Society of Thoracic Surgeons, published in 2020. Acute and subacute patients with uncomplicated TBAD presenting with an aortic diameter ≥40 mm and solely treated with BMT have an increased hazard of developing major adverse events (HR), making them potential candidates for TEVAR. Remaining risk factors analysed have weaker evidence.
Highlights
Thoracic Endovascular Aortic Repair (TEVAR) has been selectively used for uncomplicated acute type B Aortic Dissection (TBAD); not all cases will benefit from TEVAR
A trend towards an increase in the hazard of major adverse events appears to exist per 1mm increment in false lumen (FL) diameter (HR=1.05), but it did not reach significance
When reporting on false lumen diameter, measurements should “be based on a single line bisecting the center of the intimal flap perpendicular to flow”, so that true lumen and false lumen diameters add up to the total aortic diameter15; : 1) special emphasis should be placed on measuring the FL diameter at the level of the main pulmonary artery, because this is the location where a 22mm cut off for defining high risk patients was first described33, 2) authors should define cut off values for distinguishing high risk groups
Summary
Thoracic Endovascular Aortic Repair (TEVAR) has been selectively used for uncomplicated acute type B Aortic Dissection (TBAD); not all cases will benefit from TEVAR. ADSORB trial, the only RCT to compare elective TEVAR with BMT alone on uncomplicated acute TBAD patients, was not sufficiently powered for mortality at 1 year follow up. This trial did, reveal higher rates of false lumen (FL) thrombosis in patients with acute TBAD randomized to TEVAR, which was associated with fewer late complications and increased aortic remodeling[12]. Page 2: “INTRODUCTION: Thoracic Endovascular Aortic Repair (TEVAR) has been selectively used for uncomplicated acute type B Aortic Dissection (TBAD); not all cases will benefit from TEVAR.
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