Incidence,Predictors,and Implications of Secondary Aortic Intervention Following Thoracic Endovascular Aortic Repair for Type B Dissection

Abstract

Background:

Secondary aortic intervention (SAI) following thoracic endovascular aortic repair (TEVAR) is not uncommon. However, a satisfactory management system has not been established for these patients. We aimed to report our single-center experience with SAI after prior TEVAR for type B aortic dissection (TBAD).

Methods:

From January 2010 to May 2017, 860 eligible patients with TBAD underwent TEVAR. One hundred seven (12.4%) patients required SAI, either endovascularly (n=76) or surgically (n=31). The main indications for SAI were entry flow (n=58 [54.2%]), aneurysm expansion of the proximal or remote aorta (n=26 [24.3%]), retrograde type A aortic dissection (n=11 [10.3%]), distal stent-graft–induced new entry tear (n=6 [5.6%]), and stent migration (n=4 [3.7%]). The Kaplan-Meier curves were generated to determine the degree of freedom from SAI and the prognosis. Cox proportional hazards were used to screen for risk factors for SAI and poor prognosis.

Results:

The overall 30-day mortality rate after SAI was 4.7% (n=5): endovascular (n=2 [2.6%]) vs open surgery (n=3 [9.7%]; p=0.145). The cumulative survival rates with or without SAI were 86.3%±3.6% vs 95.7%±0.8% at 3 years and 82.0%±4.2% vs 92.2%±1.1% at 5 years, respectively (log-rank p<0.001). Although no significant difference in survival was observed, the incidence of SAI was significantly greater in patients who underwent TEVAR during the chronic phase (acute [11.6%] vs subacute [9.6%] vs chronic [27.8]; p<0.001). Multivariate regression analysis revealed that prior TEVAR in the chronic phase (hazard ratio [HR]=1.73, 95% confidence interval [CI]=1.03-2.90; p=0.039), maximum aortic diameter (HR=1.05, 95% CI=1.04-1.07; p<0.001), and arch involvement (HR=1.48, 95% CI=1.01-2.18; p=0.048) were predictors of the incidence of SAI. In addition, the maximum aortic diameter was demonstrated to be the only risk factor for prognosis after adjusting for confounding factors.

Conclusions:

Thoracic endovascular aortic repair for chronic TBAD patients should be reconsidered. Open surgery is preferable for those with proximal progression, whereas endovascular treatment is more suitable for distal lesions. Close surveillance and timely reintervention after TEVAR, whether via endovascular techniques or open surgery, are necessary to prevent devastating complications.

Clinical Impact

The management of patients with type B aortic dissection (TBAD) after thoracic endovascular aortic repair (TEVAR) is challenging. We summarized our single-center experience regarding secondary aortic intervention after TEVAR for TBAD. We found that TEVAR for chronic TBAD patients should be carefully evaulated, and open surgery is recommended for those with proximal progession, while endovascular treatment is more preferable for distal lesions.

Keywords

secondary aortic intervention thoracic endovascular aortic repair type B aortic dissection

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References

Erbel

Aboyans

Boileau

, et al 2014 ESC guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). Eur Heart J. 2014;35(41):2873–2926. doi:10.1093/eurheartj/ehu281.

Hiratzka

Bakris

Beckman

, et al ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease. A report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, Hiratzka LF, Bakris GL, Beckman JA, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. J Am Coll Cardiol. 2010;55(14):e27–e129. doi:10.1016/j.jacc.2010.02.015.

Evangelista

Isselbacher

Bossone

, et al Insights from the international registry of acute aortic dissection: a 20-year experience of collaborative clinical research. Circulation. 2018;137(17):1846–1860. doi:10.1161/circulationaha.117.031264.

Clough

Barillà

Delsart

, et al Editor’s choice—long-term survival and risk analysis in 136 consecutive patients with type B aortic dissection presenting to a single centre over an 11 year period. Eur J Vasc Endovasc Surg. 2019;57(5):633–638. doi:10.1016/j.ejvs.2018.08.042.

Nozdrzykowski

Luehr

Garbade

, et al Outcomes of secondary procedures after primary thoracic endovascular aortic repair. Eur J Cardiothorac Surg. 2016;49(3):770–777. doi:10.1093/ejcts/ezv279.

Shijo

Kuratani

Torikai

, et al Thoracic endovascular aortic repair for degenerative distal arch aneurysm can be used as a standard procedure in high-risk patients. Eur J Cardiothorac Surg. 2016;50(2):257–263. doi:10.1093/ejcts/ezw020.

Famularo

Meyermann

Lombardi

JV.

Aneurysmal degeneration of type B aortic dissections after thoracic endovascular aortic repair: a systematic review. J Vasc Surg. 2017;66(3):924–930. doi:10.1016/j.jvs.2017.06.067.

Alhussaini

Arnaoutakis

Scali

, et al Impact of secondary aortic interventions after thoracic endovascular aortic repair on long-term survival. Ann Thorac Surg. 2020;110(1):27–38. doi:10.1016/j.athoracsur.2019.10.015.

Giles

Beck

Lala

, et al Implications of secondary aortic intervention after thoracic endovascular aortic repair for acute and chronic type B dissection. J Vasc Surg. 2019;69(5):1367–1378. doi:10.1016/j.jvs.2018.07.080.

10.

Fillinger

Greenberg

McKinsey

, et al Reporting standards for thoracic endovascular aortic repair (TEVAR). J Vasc Surg. 2010;52(4):1022–331033. doi:10.1016/j.jvs.2010.07.008.

11.

Lombardi

Hughes

Appoo

, et al Society for Vascular Surgery (SVS) and Society of Thoracic Surgeons (STS) reporting standards for type B aortic dissections. J Vasc Surg. 2020;71(3):723–747. doi:10.1016/j.jvs.2019.11.013.

12.

Liu

Yang

Chen

, et al Management and outcomes of non-A non-B aortic dissection. Eur J Vasc Endovasc Surg. 2022;64(5):497–506. doi:10.1016/j.ejvs.2022.05.037.

13.

Sun

Zhu

, et al

Total arch replacement combined with stented elephant trunk implantation: a new “standard” therapy for type a dissection involving repair of the aortic arch?

Circulation. 2011;123(9):971–978. doi:10.1161/CIRCULATIONAHA.110.015081.

14.

Zhang

Zhao

Chen

, et al Reintervention after endovascular repair for aortic dissection: a systematic review and meta-analysis. J Thorac Cardiovasc Surg. 2016;152(5):1279–1288. doi:10.1016/j.jtcvs.2016.06.027.

15.

Miyahara

Nomura

Shirasaka

, et al Early and midterm outcomes of open surgical correction after thoracic endovascular aortic repair. Ann Thorac Surg. 2013;95(5):1584–1590. doi:10.1016/j.athoracsur.2013.02.027.

16.

Desai

Gottret

Szeto

, et al Impact of timing on major complications after thoracic endovascular aortic repair for acute type B aortic dissection. J Thorac Cardiovasc Surg. 2015;149(2, suppl):S151–6. doi:10.1016/j.jtcvs.2014.10.105.

17.

Marrocco-Trischitta

Spampinato

Mazzeo

, et al Impact of the bird-beak configuration on postoperative outcome after thoracic endovascular aortic repair: a meta-analysis. J Endovasc Ther. 2019;26(6):771–778. doi:10.1177/1526602819865906.

18.

Ding

Liu

Xie

, et al Outcomes of chimney technique for preservation of the left subclavian artery in type B aortic dissection. Eur J Vasc Endovasc Surg. 2019;57(3):374–381. doi:10.1016/j.ejvs.2018.09.005.

19.

Ding

Luo

Liu

, et al Outcomes of hybrid procedure for type B aortic dissection with an aberrant right subclavian artery. J Vasc Surg. 2018;67(3):704–711. doi:10.1016/j.jvs.2017.07.124.

20.

Chaikof

Dalman

Eskandari

, et al The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm. J Vasc Surg. 2018;67(1):2–77.e2. doi:10.1016/j.jvs.2017.10.044.

21.

Zhang

Zhou

Lin

, et al Systematic review and meta-analysis of association of prophylactic cerebrospinal fluid drainage in preventing spinal cord ischemia after thoracic endovascular aortic repair. J Vasc Surg. 2022;75(4):1478–1489. doi:10.1016/j.jvs.2021.10.050.

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