Division of Vascular Surgery and Endovascular Therapy, University of Colorado Anschutz Medical Campus, Aurora, CO.
Division of Vascular Surgery and Endovascular Therapy, University of Colorado Anschutz Medical Campus, Aurora, CO.
J Vasc Surg. 2023 May;77(5):1387-1393. doi: 10.1016/j.jvs.2022.12.064. Epub 2023 Jan 13.
The use of thoracic endovascular aortic repair (TEVAR) for the management of acute uncomplicated type B aortic dissection (TBAD) has increased. Although the results from early studies were promising, larger randomized trials evaluating TEVAR are lacking. It is also unclear where sufficient equipoise exists for such trials. In the present study, we evaluated the number of readmissions and unplanned operations after TEVAR vs those after medical management as the initial treatment of acute uncomplicated TBAD and the frequency of each treatment in this population.
We performed a multi-institutional retrospective review of patients with acute TBAD from 2015 to 2020 with the 1-year outcomes available, excluding patients with prior aortic intervention or chronic, iatrogenic or traumatic etiologies. The primary exposure was TEVAR vs medical management at the index admission. The patient demographics, clinical presentation, and imaging findings were analyzed using bivariate and multivariate logistic regression for the primary outcomes of unplanned readmission and/or operation after the initial admission. The secondary outcomes were mortality, myocardial infarction, stroke, renal failure requiring dialysis, retrograde type A dissection, and length of stay. We hypothesized that the readmissions would be higher with medical management.
A total of 216 patients with TBAD (47 with complicated and 169 with uncomplicated) from two large academic centers were identified. Of the 169 patients with uncomplicated TBAD, 83 (49%) had been treated medically and 86 (51%) had undergone TEVAR at the initial admission. No differences were found in the demographics or high-risk imaging features at presentation. The medically managed patients had had higher rates of unplanned readmission (34% vs 9%; P = .0001) and operation (28% vs 8%; P = .0007) but shorter lengths of stay (6.3 vs 13.1 days; P < .0001). No differences were found in mortality, although the rate of myocardial infarction was higher in the medically managed group (10.8% vs 2.3%; P = .02). Although 28% of the medically managed patients had later required operation, they had had morbidity and mortality similar to those of patients who had undergone initial TEVAR. Initial medical management was associated with unplanned readmission (odds ratio, 8.3; P = .02) and the need for operation (odds ratio, 4.56; P = .006). No differences were found in the outcomes according to the involved aortic zones.
In the present study, medical management of acute uncomplicated TBAD was associated with higher rates of readmission and the need for unplanned operation compared with TEVAR. However, no differences were found in the 1-year mortality for the patients for whom medical management had failed. Because one half of the patients had undergone medical management and one half had undergone early TEVAR, this finding suggests clinical equipoise for the treatment of acute uncomplicated TBAD. Therefore, a larger randomized trial appears warranted to determine whether a clear benefit exists for early TEVAR.
胸主动脉腔内修复术（TEVAR）在急性非复杂性 B 型主动脉夹层（TBAD）的治疗中应用越来越多。尽管早期研究的结果令人鼓舞，但缺乏评估 TEVAR 的更大规模随机试验。对于此类试验，尚不清楚是否存在足够的平衡。本研究评估了 TEVAR 与药物治疗作为急性非复杂性 TBAD 的初始治疗后患者的再入院和非计划手术的次数，以及该人群中每种治疗方法的频率。
我们对 2015 年至 2020 年期间接受治疗的急性 TBAD 患者进行了多机构回顾性分析，这些患者的 1 年结局可用，不包括有先前主动脉介入治疗或慢性、医源性或创伤性病因的患者。主要暴露因素是指数入院时 TEVAR 与药物治疗。使用双变量和多变量逻辑回归分析患者人口统计学、临床表现和影像学发现，以评估主要结局（初始入院后非计划再入院和/或手术）。次要结局包括死亡率、心肌梗死、卒中和需要透析的肾衰竭、逆行型 A 型夹层和住院时间。我们假设药物治疗的再入院率更高。
从两个大型学术中心确定了 216 例 TBAD 患者（47 例为复杂性，169 例为非复杂性）。在 169 例非复杂性 TBAD 患者中，83 例（49%）接受了药物治疗，86 例（51%）在初次就诊时接受了 TEVAR。在就诊时的人口统计学或高危影像学特征方面，两组无差异。药物治疗组的非计划再入院率（34%比 9%；P=0.0001）和手术率（28%比 8%；P=0.0007）较高，但住院时间较短（6.3 比 13.1 天；P<0.0001）。两组死亡率无差异，但药物治疗组心肌梗死发生率较高（10.8%比 2.3%；P=0.02）。尽管 28%的药物治疗患者后来需要手术，但他们的发病率和死亡率与最初接受 TEVAR 的患者相似。初次药物治疗与非计划再入院（优势比，8.3；P=0.02）和需要手术（优势比，4.56；P=0.006）相关。根据受累主动脉区，两组间的结局无差异。
本研究中，与 TEVAR 相比，急性非复杂性 TBAD 的药物治疗与再入院率和非计划手术的需要率较高有关。然而，药物治疗失败的患者 1 年死亡率无差异。因为一半的患者接受了药物治疗，一半的患者接受了早期 TEVAR，这一发现表明急性非复杂性 TBAD 的治疗存在临床平衡。因此，似乎需要更大规模的随机试验来确定早期 TEVAR 是否存在明确的益处。
