Outcomes of Thoracic Endovascular Aortic Repair for Acute Type B Dissection in Patients With Intractable Pain or Refractory Hypertension.

PURPOSE

To compare uncomplicated acute type B aortic dissection (UATBAD) patients with intractable pain/refractory hypertension treated with thoracic endovascular aortic repair (TEVAR) to UATBAD subjects without these features receiving best medical therapy (BMT).

METHODS

Interrogation of the hospital database identified 101 consecutive UATBAD patients admitted between January 2011 and December 2014. Of these, 74 patients (mean age 62±13 years; 44 men) were treated with BMT; the other 27 UATBAD patients (mean age 63±13 years; 17 men) were subsequently treated with TEVAR for intractable pain (24, 89%) and/or refractory hypertension (3, 11%) at a mean 2.4±3.3 days (median 1, range 0-12) after admission. Mixed models were employed to determine differences in centerline measured aortic remodeling. Propensity analysis was employed to mitigate selection bias. Kaplan-Meier methodology was used to estimate reintervention and survival.

RESULTS

The groups were well matched; there was no difference in demographics, comorbidities, or proportion with visceral involvement (70% for TEVAR vs 86% for BMT, p=0.08). There was no significant difference in length of stay (9.6±6.3 for TEVAR vs 10.3±7.8 for BMT, p=0.3), complications (19% for TEVAR vs 24% for BMT, p=0.6), or 30-day mortality (0 for TEVAR vs 7% for BMT, p=0.1). One (4%) TEVAR patient experienced retrograde dissection. BMT resulted in greater mean increase in discharge antihypertensive medications (1.7±1.9 vs 0.7±1.7 for TEVAR, p=0.03), but there was no difference in narcotic utilization. Mean follow-up was greater in the TEVAR group (17.9±16.0 months) compared with BMT patients (11.5±10.8 months, p=0.05). TEVAR significantly improved rates of aortic diameter change (1.5% vs 12.9% for BMT, p=0.007), complete false lumen thrombosis (41% vs 11% for BMT, p=0.004), and true lumen expansion (85% vs 7% for BMT, p<0.01). However, there was no difference in reintervention (25.9% for TEVAR vs 23% for BMT, p=0.2) or survival (log-rank p=0.8).

CONCLUSION

TEVAR for UATBAD with intractable pain/refractory hypertension is safe but offers no short-term outcome advantage when compared to UATBAD patients without these features receiving BMT. A significant improvement in aortic remodeling was identified after TEVAR. The potential long-term reintervention and aorta-related mortality benefits of this favorable remodeling have yet to be defined and randomized trials are warranted.