Outcomes of thoracic endovascular aortic repair for uncomplicated type B dissections based on chronicity

Abstract

Objective: The long-term results of thoracic endovascular aortic repair (TEVAR) for uncomplicated type B aortic dissection (uTBAD) have been associated with improved aorta-specific survival and delayed disease progression compared with medical therapy alone. In 2020, the Society for Vascular Surgery (SVS) and Society for Thoracic Surgeons (STS) reported new reporting standards and classification for TBAD. We assessed the effectiveness of TEVAR in the treatment of uTBAD stratified by the updated classification using the Vascular Quality Initiative database.

Methods: The Vascular Quality Initiative registry was queried for patients who had undergone TEVAR for uTBAD from August 2014 to November 2020. We analyzed the outcomes stratified by the SVS/STS reporting standards. The cohort was then grouped and compared using the updated chronicity classification (hyperacute, <24 hours; acute, 1-14 days; subacute, 15-90 days; and chronic, >90 days) and univariable methods (χ², analysis of variance), multivariable logistic regression, and survival analysis (Kaplan-Meier, Cox regression).

Results: Of 1476 TEVARs, 121 (8.2%) were for hyperacute, 833 (56.4%) for acute, 316 (21.4%) for subacute, and 206 (14.0%) for chronic uTBAD. The rates of in-hospital stroke for hyperacute and acute uTBAD were significantly higher than was the rate for chronic uTBAD. The rate of spinal cord ischemia (SCI) was significantly higher for hyperacute and subacute uTBAD than for chronic uTBAD but not for acute vs chronic uTBAD. After multivariable adjustment, no significant difference was found in the 30-day mortality between the four groups. However, the adjusted stroke risk was more than sixfold higher for hyperacute uTBAD than for chronic uTBAD (odds ratio [OR], 6.78; 95% confidence interval [CI], 1.83-25.17; P = .004) and more than threefold higher for acute than for chronic uTBAD (OR, 3.42; 95% CI, 1.04-11.24; P = .043). The adjusted risk of SCI was also significantly higher for hyperacute and subacute than for chronic uTBAD (OR, 19.17; 95% CI, 2.42-151.90; P = .005; and OR, 8.64; 95% CI, 1.11-67.21; P = .039, respectively) but not for acute vs chronic uTBAD (OR, 6.95; 95% CI, 0.93-51.88; P = .059). The risk of postoperative reintervention was threefold higher for hyperacute vs chronic uTBAD (OR, 3.02; 95% CI, 1.19-7.69; P = .02). The Kaplan-Meier survival estimates revealed that the 1-year survival rate for hyperacute, acute, subacute, and chronic uTBAD was 83.2%, 87.2%, 92.3%, and 92.9%, respectively (P = .010). However, no significant differences were found in the hazard of 1-year mortality after adjustment for potential confounders.

Conclusions: Using the updated SVS/STS chronicity classification, we found an increased risk of perioperative stroke, SCI, and the need for reintervention after TEVAR for uTBAD in the hyperacute periods compared with the chronic period. The updated classification should be incorporated into all future study designs for TEVAR trials. We would recommend avoiding TEVAR for uTBAD in the hyperacute phase.

Keywords: TEVAR; Uncomplicated type B aortic dissection.