Thoracic Endovascular Aortic Repair vs Medical Therapy Alone for Uncomplicated Acute Type B Aortic Dissection

Abstract

It remains controversial if thoracic endovascular aortic repair (TEVAR) or optimal medical therapy (OMT) should be the standard of care for uncomplicated type B aortic dissection (uTBAD). We evaluate our institutional experience to compare the outcomes of TEVAR vs OMT as primary treatment for uTBAD. Data were analyzed to compare early and late outcomes of 219 patients (135 men; 61.6%) with uTBAD who were triaged to OMT in 162 and TEVAR in 57 over 3 decades. Mean age was 64.5 ± 12.7 and 63.5 ± 15.9 years (P = .630) in the TEVAR and OMT groups, respectively. TEVAR group had significantly higher incidences of hypertension (87.8% vs 40.1; P < .001), smoking (63.2% vs 38.3%; P = .002), dyslipidemia (47.4% vs 16.7%; P < .001), chronic kidney disease (17.5% vs 6.2%; P = .016), and prior stroke/transient ischemic attack (14% vs 4.9%; P = .035). After TEVAR, neither death nor paraplegia occurred, while seven patients developed acute kidney injury not requiring hemodialysis (12.3%), and one sustained stroke (1.8%). In-hospital/30-day mortality was 0% with TEVAR vs 16% (26/162) with OMT (P < .001). Follow-up was 100% (193/193) at a median of 5.8 years (mean, 7.8; interquartile range [IQR], 2.0-12.3). In OMT group, 70 patients died at median 5.2 years (IQR, 2.0-8.8 years), and 72 underwent intervention at median 85 days (IQR, 0.01-1.2 years), including open descending repair in 60, TEVAR in 9, abdominal aortic repair in 2, and arch repair in 1. Following intervention, 40 died at median 1.8 years (IQR, 0.02-6.3 years). In TEVAR group, 18 underwent reintervention at median 48.5 days (IQR, 29-101 days), including 11 redo-TEVAR, 3 EVARs, 1 hemiarch, and 3 others; all were alive at latest follow-up except 1 expiring at 6.9 months postreintervention. At 3 months, 1 year, and 3 years following treatment, survival rates were significantly higher in TEVAR vs OMT patients (100% vs 83.2 ± 2.9%; 94.4 ± 3.1 vs 77.0 ± 3.3%; and 91.8 ± 4.0% vs 67.9 ± 3.7%) (P = .002, Fig 1); the respective freedom from (re)intervention were 75.4 ± 5.7% vs 72.7 ± 3.6%, 68.0 ± 6.2% vs 64.2 ± 3.9%, and 68.0 ± 6.2% vs 53.0 ± 4.2% (P = .198) in TEVAR vs OMT groups. After (re)intervention, the group with initial TEVAR had improved survival (94.4 ± 5.4% up to 3 years) compared to OMT patients (76.4 ± 5.0 at 1 year, 65.3 ± 5.6% at 3 years) (P = .039) (Fig 2). In the management of uTBAD, patients receiving initial OMT showed lower survival and required more intervention, while initial TEVAR achieved significantly higher survival up to 3 years, even after reintervention. These results argue favorably for the use of TEVAR as the primary treatment of choice for uTBAD.Fig 2Survival after (re)intervention, Kaplan-Meier survival curve comparing survival postsurgical (re)intervention after initial treatment by either thoracic endovascular aortic repair (TEVAR) or medical therapy up to 3 years after treatment. Log-rank P = .039.View Large Image Figure ViewerDownload Hi-res image Download (PPT)