Complicated acute type B aortic dissections require urgent intervention. Our group has previously reported successful treatment of this condition with TEVAR. We report our continued experience, and contrast the technical aspects and outcomes of malperfusion vs. rupture.
Methods
From 2004-2008, 43 patients (60 ± 13 years; 28 men) with an acute complicated type B dissection underwent TEVAR. Indications for treatment were malperfusion - 26 (60%) and rupture - 22 (51%); 5 (11%) presented with both. Renal malperfusion was present in 17 (65%), visceral - 17 (65%), lower extremity - 14 (54%). Patients were followed 1 to 49 months (16 ± 12).
Results
Excellent technical and clinical results were achieved in both groups. Onset of intervention was significantly earlier in patients with rupture (0.6 vs. 1.9 days, p=0.02). Endograft utilization and deployment were comparable, including device number (2.1; 2.2; p=0.94), left SCA coverage (17; 16; p=0.58), and celiac coverage (0; 0). One-year survival was greater than 94% in both groups. While length of stay was longer with malperfusion, neither presentation conferred an inferior outcome (Table). Although TEVAR alone effectively treated aortic rupture in 21 patients (95%), malperfusion was rectified in only 15 (58%) cases. Eleven patients (42%) required adjunctive procedures to restore end-organ perfusion: 50% -lower extremity, 18% - renal, 12% - visceral. No patient suffered limb loss or bowel resection; renal function recovered in 94% of patients with malperfusion.
Malperfusion
Rupture
P value
ICU stay (days)
5.1±0.8
6.4±0.8
0.98
LOS (days)
19.6±2.5
13.2±1.2
0.04
Blood products (patients)
15/26
9/22
0.59
Stroke (patients)
0/26
1/22
0.93
Spinal ischemia (patients)
2/26
1/22
0.65
30-day mortality (patients)
0/26
1/22
0.93
1-year survival (patients)
21/22
16/17
0.85
Conclusions
Malperfusion and rupture complicating acute type B aortic dissection are both successfully managed with TEVAR. However, the endovascular strategy must be customized to each presentation to achieve these results. While TEVAR alone is sufficient to address the aortic disruption in patients with rupture, adjunctive procedures are often necessary in malperfusion cases.
Hospital of University of Pennsylvania, Philadelphia, PA
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