FavorableImpact of TEVAR on Long-term Survival in Patients with Acute Uncomplicated TypeB Aortic Dissection
James C. Iannuzzi, MD MPH, Sahael M. Stapleton, MD, Yanik J. Bababekov, MD MPH, David C. Chang, PhD MBA MPH, Robert T. Lancaster, MD MPH, Mark F. Conrad, MD MSSc, Richard P. Cambria, MD, Virendra I. Patel, MD MPH.
Massachusetts General Hospital, Boston, MA, USA.
Standard non-operative medical therapy for uncomplicated type-B dissection has been questioned by recent studies demonstrating improved outcomes in those treated with thoracic endovascular aortic repair (TEVAR). This study assessed long-term survival after acute uncomplicated type-B dissection comparing medical therapy, open repair, and TEVAR.
The California Office of Statewide Hospital Planning Development database was analyzed from 2000-2010. Patients with emergent admission for aortic dissection were identified and those with type-A dissection, trauma, bowel ischemia, lower extremity ischemia, acidosis, or shock were excluded. The cohort was stratified by treatment type at index admission into medical (MED), open repair (OPEN), and TEVAR. Bivariate, multivariable, and survival analyses were utilized to evaluate the impact of treatment type on long-term overall survival.
There were 9,165 uncomplicated type-B dissections admitted, of which 95% were MED, 2.0% OPEN, and 2.9% TEVAR. Mean age was 66 ± 15 years, with 39% female, 2.4% cocaine users, 18% with CHF, 17% with a Charlson co-morbidity score>3. Mean length of stay was 6.7 ± 8.9 days in MED, 15±15 days in OPEN, and 12 ± 10 days in TEVAR (P<0.001); mean inpatient costs were $57,000 MED, $200,000 OPEN, and $130,000 TEVAR (P<0.001). Overall inpatient mortality was 6.5%, 6.3% for MED, 14% for OPEN, and 7.1% for TEVAR (P<0.001). Overall 30-day, 1-year and 5-year survival were 86%±0.4%, 76%±0.4% and 60±0.6%, in MED were 86%±0.4%, 84%±2%, and 60±0.6%; in OPEN were 83±3%, 76%±0.5%,and 67±4%, and in TEVAR were 93%±2%, 85%±2% and76±4% respectively (Figure 1, Log Rank P<0.01). On risk adjusted multivariable analysis TEVAR improved survival [HR 0.68 (95% confidence interval: 0.55-0.83); P<0.01] compared to MED (Table 1).
This study assessing statewide survival following acute uncomplicated type B dissections shows an independent survival advantage for TEVAR over the longstanding practice of medical therapy These data add further evidence for a paradigm shift in acute management of type b dissection and support initiating randomized controlled trials of TEVAR for acute uncomplicated type B dissections.
Back to 2017 Program