Preemptive treatment in the acute and early subacute phase of uncomplicated type B aortic dissections with poor prognosis factors

Abstract

Objective: Due to its favorable outcome regarding late morbidity and mortality, thoracic endovascular repair (TEVAR) is becoming more popular for uncomplicated type B aortic dissection (TBAD). This study aimed to compare preemptive endovascular treatment and optimal medical treatment (OMT) and OMT alone in patients presenting uncomplicated TBAD with predictors of aortic progression.

Design: Retrospective multicenter study.

Methods: We analyzed patients with uncomplicated TBAD and risk factors of progression in two French academic centers. Aortic events [defined as aortic-related (re)intervention or aortic-related death after initial hospitalization], postoperative complications, non-aortic events, and radiologic aortic progression and remodeling were recorded and analyzed. Analysis was performed on an intention-to-treat basis.

Results: Between 2011 and 2021, preemptive endovascular procedures at the acute and early subacute phase (<30 days) were performed on 24 patients (group 1) and OMT alone on 26 patients (group 2). With a mean follow-up of 38.08 ± 24.53 months, aortic events occurred in 20.83% of patients from group 1 and 61.54% of patients from group 2 (p < .001). No patient presented aortic-related death during follow-up. There were no differences in postoperative events (p = 1.00) and non-aortic events (p = 1.00). OMT patients had significantly more aneurysmal progression of the thoracic aorta (p < .001) and maximal aortic diameter (p < .001). Aortic remodeling was found in 91.67% of patients in group 1 and 42.31% of patients in group 2 (p < .001). A subgroup analysis of patients in group 1 showed that patients treated with preemptive TEVAR and STABILISE had reduced maximum aortic diameters at the 1-year (p = .010) and last follow-up (p = .030) compared to those in patients treated with preemptive TEVAR alone.

Conclusion: Preemptive treatment of uncomplicated TBAD with risk factors of progression reduces the risk of long-term aortic events. Over 60% of medically treated patients will require intervention during follow-up, with no benefit in terms of postoperative events. Even after surgical treatment, patients in the OMT group had significantly more aneurysmal progression, along with poorer aortic remodeling.

Keywords: aneurysmal evolution; comparative study; optimal medical treatment; preemptive endovascular treatment; risk factors; uncomplicated type B aortic dissection.

Figure 1

Complete aortic remodeling with false lumen shrinkage.

Figure 2

Cumulative Kaplan–Meier estimate of patient survival without intervention over time after aortic dissection (AD) in group 1 (preemptive endovascular treatment in addition to OMT) and group 2 (OMT alone).

Figure 3

Mean aortic diameter of maximum, thoracic, thoracoabdominal (TA), and abdominal aorta in group 1 (preemptive endovascular treatment in addition to OMT) and group 2 (OMT alone). NS, non-significant.

Figure 4

Boxplot showing thoracoabdominal diameter (A) and maximum aortic diameter (B) in patients treated by OMT alone (group 2) and the subgroup analysis of patients in group 1 treated by preemptive TEVAR or by preemptive TEVAR and STABILISE. Initially, thoracoabdominal diameters were 30.0 mm ± 3.2 mm, 30.6 mm ± 3.2 mm, and 32.0 mm ± 1.6 mm for patients treated with OMT, TEVAR and STABILISE, and TEVAR, respectively (p = .40). At 1-year follow-up, the diameters were 33.2 mm ± 14.2 mm, 36.2 mm ± 15.8 mm, and 36.6 mm ± 14.9 mm for patients treated with TEVAR and STABILISE, OMT, and TEVAR, respectively (p = .16). At the last follow-up, the diameters were 33.5 mm ± 14.9 mm, 36.7 mm ± 16.9 mm, and 40. mm ± 18.6 mm for patients treated with TEVAR and STABILISE, OMT, and TEVAR, respectively (p = .090). (A) Initially, the maximum aortic diameters were 39.4 mm ± 4.9 mm, 42.5 mm ± 5.8 mm, and 45.2 mm ± 5.3 mm for patients treated with OMT, TEVAR and STABILISE, and TEVAR, respectively (p = .040). At 1-year follow-up, the diameters were 40.3 mm ± 4.6 mm, 46.6 mm ± 8.1 mm, and 47.6 mm ± 9.9 mm for patients treated with TEVAR and STABILISE, OMT, and TEVAR, respectively (p = .010). At the last follow-up, the diameters were 40.7 mm ± 4.7 mm, 47.8 mm ± 10.1 mm, and 52.4 mm ± 15.8 mm for patients treated with TEVAR and STABILISE, OMT, and TEVAR, respectively (p = .030) (B).

Figure 5

The number of patients with aneurysmal progression of the maximum thoracic diameter (A) or reaching a diameter >50 mm (B) in patients treated by OMT alone (group 2) and the subgroup analysis of patients in group 1 treated by preemptive TEVAR or by preemptive TEVAR and STABILISE.

Figure 6

The number of patients with total aortic remodeling in patients treated by OMT alone (group 2) and the subgroup analysis of patients in group 1 treated by preemptive TEVAR or by preemptive TEVAR and STABILISE.