Nationwide outcomes of early thoracic endovascular aortic repair for type B aortic dissection.

Abstract

Early endovascular repair of the thoracic aorta (TEVAR) is the standard-of-care for complicated type B aortic dissection (cTBAD) but remains controversial in high-risk (hrTBAD) and uncomplicated TBAD (uTBAD). The aim of this study was to evaluate long-term survival and determine risk factors associated with survival and reintervention in cTBAD, hrTBAD, and uTBAD. This population-based retrospective study included adults with acute TBAD from 2010 to 2022 in the National Minimum Dataset (NMDS), a database of all public hospital admissions across Aotearoa New Zealand. Chronic, traumatic, iatrogenic, or incidental TBAD and intramural hematoma without dissection were excluded. Clinical records were manually reviewed to verify diagnoses, survival, and comorbidities. Patients were classified as cTBAD if they had clinical malperfusion or signs of rupture, hrTBAD if there was rapid aortic expansion on interval imaging, refractory hypertension or pain, or radiological malperfusion, and uTBAD in the absence of these features. An early TEVAR was defined as a procedure within 90 days from the index dissection. Cox proportional hazard models were used for all-cause mortality and the need for further intervention. A total of 420 patients with acute TBAD were included (mean age, 64.3 years; 37.4% female; 22.4% with cTBAD). Initial management was medical in 70.5%, TEVAR in 26.0%, and open aortic repair in 3.6%. The median follow-up time was 3.2 years, accounting for mortality (interquartile range, 1.4-6.3 years). TEVAR was associated with lower adjusted all-cause mortality in cTBAD compared with best medical therapy (hazard ratio [HR], 0.06; 95% confidence interval [CI], 0.01-0.28; P < .001), but not in uTBAD (HR, 0.89; 95% CI, 0.39-2.00; P = .770) or hrTBAD (HR, 0.49; 95% CI, 0.20-1.19; P = .115). TEVAR had a similar need for further intervention compared with best medical therapy in hrTBAD (HR, 0.66; 95% CI, 0.19-2.27; P = .513) and uTBAD (HR, 2.36; 95% CI, 0.82-6.81; P = .114). This nationwide study found early TEVAR is associated with increased adjusted all-cause survival in cTBAD, but not in hrTBAD or uTBAD. The need for further aortic intervention in TBAD remains high regardless of initial medical or TEVAR management.