RS17. Long-term Outcomes of Acute Uncomplicated Medically Managed Stanford Type B Aortic Dissection

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The objective of this study was to elucidate outcomes and preceding changes in aortic anatomy after acute uncomplicated medically managed Stanford type B aortic dissection (SBAD). This is an observational study of medically managed SBAD with index admission to a single center between 1995 and 2015. Follow-up was conducted, which captured aorta-related events, measurable changes in aortic anatomy on computed tomography and magnetic resonance imaging, and mortality with coded causes of death provided by the Centers for Disease Control and Prevention National Death Index. Descending thoracic aorta aneurysm was defined by a maximum orthogonal diameter ≥40 mm. Cardiac and cerebrovascular events were identified secondarily. There were 94 patients with acute medically managed SBAD identified, and follow-up was conducted for the 88 (94%) who survived the index hospitalization (median [interquartile range] outcome follow-up durations: clinical, 4.1 [1.1-10] years; radiologic, 3.1 [1.1-7] years; mortality, 6.8 [3.8-12] years). At the end of follow-up, 46 (52%) patients were deceased, and 57 (64.8%) had experienced one or more aorta-related events. Aorta-related events included death in 15 (17%), descending thoracic aorta aneurysm in 20 (63% of 32 without aneurysm during index admission), aortic rupture in 9 (10%), descending thoracic aorta repair or fenestration in 33 (38%), and intimal-medial flap changes in 8 (9%; 6 flap extensions, 2 new dissections). The net change in orthogonal maximum descending thoracic aorta diameter between the index hospitalization and imaging preceding an aortic event is depicted in Fig 1. Aorta-related event-free survival was 68.7% (59.4%-79.5%) at 6 months, 56.9% (47%-68.9%) at 1 year, and 33.9% (24.3%-47.3%) at 5 years. Women had statistically similar event-free survival to men in follow-up (hazard ratio [95% confidence interval], 0.65 [0.37-1.15]; P = .1; Fig 2). Factors independently associated with having an aorta-related event during follow-up were age (hazard ratio [95% confidence interval], 0.98 [0.96-1]; P = .02), congenital cardiovascular disease (3.18 [1.25-8.09]; P = .02), connective tissue disease (2.3 [1.25-8.09]; P = .01), and refractory pain (3.64 [1.11-11.87]; P = .03). Throughout follow-up, 25 (28.4%) patients experienced one or more cardiac or cerebrovascular events, including death in 13 (50%), myocardial infarction in 8 (32%), heart failure in 12 (48%), and stroke in 7 (28%). Event-free survival was 93.5% (88.1%-99.2%) at 6 months, 90.7% (84.4%-97.5%) at 1 year, and 76.9% (67.1%-88.2%) at 5 years. Patients with medically managed SBAD had poor aorta-related event-free survival with many events occurring early in follow-up. These findings corroborate previous work and highlight the need for a better understanding of risk factors for aorta-related events to guide timely and appropriate intervention.Fig 2Freedom from aorta-related event by sex.View Large Image Figure ViewerDownload Hi-res image Download (PPT)