Division of Vascular Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY.
Division of Biostatistics, Population and Public Health Sciences, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA.
J Vasc Surg. 2024 Sep;80(3):656-664. doi: 10.1016/j.jvs.2024.03.458. Epub 2024 May 7.
The technical aspects of thoracic endovascular aortic repair (TEVAR) for acute type B aortic dissection (TBAD), specifically the location of proximal seal zone (PSZ) (need to cover the left subclavian artery [LSA]), distal seal zone (DSZ) (length of aortic coverage), benefit of LSA revascularization, and prophylactic lumbar drainage are still debated. Each of these issues has potential benefits but also has known risks. This study aims to identify factors associated with reintervention and spinal cord ischemia (SCI) following TEVAR for acute TBAD with a zone 3 entry tear.
The Vascular Quality Initiative was queried for TEVARs performed for acute TBAD with zone 3 entry tear, zone 3 proximal zone of disease, treated with TEVAR extending between zone 2 and zone 5. The primary outcomes were SCI and related reintervention. Secondary outcomes were stroke, arm ischemia, and retrograde type A dissection (RTAD). The exposure variables were PSZ 2 vs 3, DSZ 4 vs 5, prophylactic lumbar drain, and LSA revascularization. Univariate analyses were conducted with χ analysis, and multivariable logistic regression was used to evaluate association with outcomes.
Of 583 patients who met inclusion criteria, 266 had PSZ 2 and 317 had PSZ 3. On univariate analysis, PSZ 2 was associated with a higher rate of reintervention, but PSZ2 was not significant on multivariable analysis after accounting for age, sex, race, smoking, PSZ, DSZ, prophylactic lumbar drain, and LSA patency. PSZ 2 was not associated with SCI, arm ischemia, or RTAD. PSZ 2 was associated with a trend towards a higher rate of stroke. DSZ 4 and DSZ 5 were performed in 161 and 422 TEVARs, respectively, and DSZ 5 was associated with a higher rate of SCI on univariate (3 [1.9%] vs 39 [9.2%]; P = .01) and multivariable (odds ratio, 7.384; 95% confidence interval, 2.193-24.867; P = .001) analyses. Prophylactic lumbar drain placement was not statistically significantly associated with SCI, but lack of postoperative LSA patency was associated with SCI (odds ratio, 2.966; 95% confidence interval, 1.016-8.656; P = .05).
This study found that PSZ 2 was not associated with lower reinterventions or higher rates of SCI but trended towards a higher rate of stroke than PSZ 3. Additionally, DSZ 5 was strongly associated with SCI when compared with DSZ 4, highlighting the importance of limiting aortic coverage to coverage of the proximal entry tear when possible.
胸主动脉腔内修复术（TEVAR）治疗急性 B 型主动脉夹层（TBAD）的技术方面，特别是近端密封区（PSZ）的位置（需要覆盖左锁骨下动脉[LSA]）、远端密封区（DSZ）（主动脉覆盖长度）、LSA 血运重建的益处和预防性腰引流，仍存在争议。这些问题中的每一个都有潜在的好处，但也有已知的风险。本研究旨在确定与急性 TBAD 合并 3 区入口撕裂行 TEVAR 后再干预和脊髓缺血（SCI）相关的因素。
血管质量倡议（Vascular Quality Initiative）对急性 TBAD 合并 3 区入口撕裂、3 区近端病变区、采用 2 区至 5 区 TEVAR 治疗的病例进行了检索。主要结果是 SCI 和相关的再干预。次要结果是中风、手臂缺血和逆行型 A 型夹层（RTAD）。暴露变量为 PSZ 2 与 3、DSZ 4 与 5、预防性腰引流和 LSA 血运重建。采用卡方检验进行单变量分析，多变量逻辑回归用于评估与结果的关联。
在符合纳入标准的 583 例患者中，266 例 PSZ 2，317 例 PSZ 3。单变量分析显示，PSZ 2 与再干预率较高相关，但多变量分析显示，在考虑年龄、性别、种族、吸烟、PSZ、DSZ、预防性腰引流和 LSA 通畅性后，PSZ 2 无统计学意义。PSZ 2 与 SCI、手臂缺血或 RTAD 无关。PSZ 2 与中风发生率较高呈趋势相关。DSZ 4 和 DSZ 5 分别在 161 例和 422 例 TEVAR 中进行，DSZ 5 与 SCI 的单变量（3[1.9%]与 39[9.2%]；P=.01）和多变量（比值比，7.384；95%置信区间，2.193-24.867；P=.001）分析相关。预防性腰引流的放置与 SCI 无统计学显著相关性，但术后 LSA 通畅性与 SCI 相关（比值比，2.966；95%置信区间，1.016-8.656；P=.05）。
本研究发现 PSZ 2 与较低的再干预率或较高的 SCI 发生率无关，但与 PSZ 3 相比，中风发生率呈上升趋势。此外，与 DSZ 4 相比，DSZ 5 与 SCI 强烈相关，这突出了在可能的情况下限制主动脉覆盖范围以覆盖近端入口撕裂的重要性。
