Thoracic endovascular aortic repair for hyperacute, acute, subacute and chronic type B aortic dissection: Meta-analysis of reconstructed time-to-event data

Weighted 10-year survival and neurological outcomes after zone 2 thoracic endovascular aortic repair for acute type B aortic dissection

OBJECTIVE

The long-term benefits of left subclavian artery (LSA) revascularization during thoracic endovascular aortic repair (TEVAR) for patients with acute type B aortic dissection (aTBAD) remain controversial. This study aimed to evaluate the impact of LSA revascularization during TEVAR on short- and long-term survival and neurological outcomes in aTBAD patients.

METHODS

We retrospectively analyzed data from consecutive aTBAD patients undergoing zone 2 TEVAR between 2010 and 2020 at one Chinese national aortic center. Inverse probability of treatment weighting (IPTW) was employed to mitigate baseline differences between LSA coverage and revascularization groups. Long-term survival, freedom from major adverse cardiovascular events (MACE), ischemic stroke rates, and cerebrovascular accident (CVA) rates were assessed using the Kaplan-Meier analysis. Weighted logistic and Cox regression models was applied to identify predictors of short- and long-term outcomes.

RESULTS

The final analysis included 253 patients. Intergroup balance was achieved after IPTW. After LSA revascularization, incidences of postoperative type II endoleak (38.9% vs. 38.2%, p=0.91), post implantation syndrome (38.0% vs. 38.5%, p=0.938), 30-day mortality (0.6% vs. 1.1%, p=0.568), and early CVA (0.6% vs. 0.5%, p=0.931) were comparable between groups. There was no significant difference in CVA incidence (4.8% vs. 12.1%, p=0.34) or freedom from MACE (91.2% vs. 78.5%, p=0.55) at 10-year follow-up. Weighted multivariable analysis identified post implantation syndrome (PIS) after TEVAR as an independent predictor of CVA (HR=2.65, 95% CI 1.10-6.42, p=0.03).

CONCLUSION

LSA revascularization during TEVAR does not increase risks for perioperative or long-term morbidities. Ischemic stroke rates, CVA rates, survival, and MACE-free survival were statistically comparable between groups at 5- and 10-year follow-up. PIS emerged as a significant CVA risk factor after zone 2 TEVAR for aTBAD.

Pre-Emptive Endovascular Repair for Uncomplicated Type B Dissection - Is This an Option?

Type B aortic dissection (TBAD) primarily affects men aged 60-65 years, with hypertension in over 80% of cases. The gold standard for the treatment of uncomplicated acute TBAD is Best Medical Treatment (BMT), which focused on controlling blood pressure and heart rate. However, Thoracic Endovascular Aortic Repair (TEVAR) has gained attention over the years, especially for complicated TBAD cases, by covering the primary entry tear, lowering false lumen pressure, and promoting aortic remodeling. TBAD can be classified according to the onset of symptoms into acute, subacute and chronic stages, with different intervention implications at each stage. Studies such as the Acute Dissection Stentgraft OR Best Medical Treatment and Investigation of STEnt grafts in Acute Dissection trials have shown the benefits of TEVAR over BMT, particularly in promoting aortic remodeling and reducing long-term aorta-related mortality. However, these trials noted no significant difference in immediate mortality. TEVAR timing is crucial, as early intervention in the acute phase can lead to higher complication rates due to higher intimal fragility. As a result, the subacute phase offers a balance, allowing beneficial remodeling with a lower complication rate.

Percutaneous Coronary Intervention or Minimally Invasive Coronary Bypass for Isolated Left Anterior Descending Artery Disease

The optimal revascularization strategy for isolated left anterior descending (LAD) artery disease, minimally invasive direct coronary artery bypass (MIDCAB) and percutaneous coronary intervention (PCI), remains a subject of debate. This updated meta-analysis aimed to compare the long-term outcomes of MIDCAB versus PCI for patients with isolated LAD artery disease. Three databases were systematically searched to identify randomized controlled trials (RCTs) and adjusted studies. Primary outcomes included long-term survival and repeat target vessel revascularization (TVR). The secondary endpoint was long-term major adverse cardiovascular events (MACEs). Hazards ratios (HR) and Confidence Intervals (CI) were calculated for long-term outcomes and a random effects model was used. Sensitivity analyses included subgroups analysis of stent-type. Nine articles, comprising 4 RCTs, totaling 2,168 patients (MIDCAB = 1,086 and PCI = 1,080) were included. The weighted mean follow-up was 4.35 ± 4.9 years. Long-term survival was comparable between MIDCAB and PCI (HR = 0.76; 95% CI, 0.58 to 1.00; p = 0.05). MIDCAB was associated with a significantly lower rate of repeat TVR (HR = 0.35; 95% CI, 0.25 to 0.49; p <0.0001) and a reduced risk of MACEs (HR = 0.59; 95% CI, 0.43 to 0.81; p <0.0001), although the difference was not evident in subgroup analysis comparing MIDCAB and PCI with drug-eluting stent (HR = 0.66; 95% CI, 0.46 to 1.06; p = 0.09). In conclusion, this meta-analysis of RCTs and adjusted studies shows that in patients with isolated LAD lesion, MIDCAB and PCI exhibit comparable long-term survival. However, MIDCAB is associated with a significantly reduced risk of long-term repeat TVR and MACEs compared to PCI.

Comparisons of open surgical repair, thoracic endovascular aortic repair, and optimal medical therapy for acute and subacute type B aortic dissection: a systematic review and meta-analysis

BACKGROUND

Various treatments have been employed in managing type B aortic dissection (TBAD), encompassing open surgical repair (OSR), thoracic endovascular aortic repair (TEVAR), and optimal medical therapy (OMT). Nonetheless, the determination of the most efficacious treatment protocol remains a subject of debate. We aim to compare the treatments in patients with acute and subacute TBAD using a meta-analytic approach.

METHODS

A systematic search was conducted across databases including PubMed, EmBase, and the Cochrane Library for relevant studies published from their inception up to September 2024. Studies comparing OSR, TEVAR, and OMT for TBAD through controlled or direct comparative designs were incorporated. Pairwise comparison meta-analyses were performed employing odds ratios (OR) alongside 95% confidence intervals (CIs) to quantify intervention effects by using the random-effects model.

RESULTS

Thirty-one studies involving 34,681 patients with TBAD were included in the final meta-analysis. We noted OSR were associated with an increased risk of in-hospital mortality (OR: 2.41; 95%CI: 1.67-3.49; P < 0.001), paraplegia (OR: 3.60; 95%CI: 2.20-5.89; P < 0.001), limb ischemia (OR: 7.80; 95%CI: 2.39-25.49; P = 0.001) and bleeding (OR: 9.54; 95%CI: 6.57-13.85; P < 0.001) as compared with OMT. Moreover, OSR versus TEVAR showed an increased risk of in-hospital mortality (OR: 2.67; 95%CI: 1.92-3.72; P < 0.001), acute renal failure (OR: 1.98; 95%CI: 1.61-2.42; P < 0.001), myocardial infaraction (OR: 2.76; 95%CI: 1.64-4.65; P < 0.001), respiratory failure (OR: 2.19; 95%CI: 1.73-2.76; P < 0.001), or bleeding (OR: 1.88; 95%CI: 1.33-2.67; P < 0.001), and lower risk of reintervention (OR: 0.30; 95%CI: 0.10-0.89; P = 0.030). Finally, TEVAR was associated with an increased risk of stroke (OR: 1.77; 95%CI: 1.41-2.21; P < 0.001), limb ischemia (OR: 13.00; 95%CI: 4.33-39.06; P < 0.001), and bleeding (OR: 3.65; 95%CI: 2.40-5.55; P < 0.001) as compared with OMT.

CONCLUSIONS

This study systematically compared various treatments and showed their safety and efficacy for acute and subacute TBAD. The results require further large-scale randomized controlled trials.

Time is Aorta in Uncomplicated Type B Aortic Dissection

BACKGROUND

Although cardiovascular control optimization through best medical therapy remains the gold standard of treatment for uncomplicated type B aortic dissection (uTBAD) according to international guidelines, thoracic endovascular aortic repair (TEVAR) has increasingly emerged as a viable and appealing treatment option due to its potential to induce favorable aortic remodeling and improve long-term outcomes. However, the optimal timing of TEVAR in uTBAD remains a subject of debate. This narrative review aims at evaluating safety, efficacy, and outcomes of TEVAR at different time points of the disease history.

METHODS

We conducted a comprehensive literature review across multiple electronic databases, including PubMed and Scopus, to synthesize research evidence on the timing of TEVAR in uTBAD.

RESULTS

Hyperacute-phase TEVAR (<24 hours) is associated with prohibitive periprocedural risks and is thus discouraged. Acute-phase TEVAR (1-14 days) may provide benefits in aortic remodeling but it is burdened by rather elevated rates of early complications and reinterventions. The subacute phase (14-90 days) is consistently identified as the optimal therapeutic window, balancing procedural safety and efficacy, with studies reporting superior outcomes in terms of mortality, complications, and aortic remodeling. Chronic-phase TEVAR (>90 days), although sometimes necessary in cases of disease progression, is associated with poorer outcomes, including higher rates of reintervention, complications, and limited aortic remodeling with respect to the subacute phase.

CONCLUSION

The consistent findings across the studies analyzed indicate that the subacute phase offers the best combination of reduced procedural risks and favorable long-term outcomes. However, stronger evidence is needed to refine timing strategies.

Hospital Teaching Status and Outcomes in Type B Aortic Dissection: Analysis of More Than 40,000 Patients

OBJECTIVE

To assess the association of hospital teaching status with outcomes of patients presenting with type B aortic dissection (TBAD).

DESIGN

Retrospective cross-sectional study of the National Readmissions Database (NRD), from 2016 to 2020.

SETTING

Hospitals across the United States stratified by teaching status.

PARTICIPANTS

TBAD patients.

INTERVENTIONS

Surgical repair, thoracic endovascular aortic repair (TEVAR), and conservative medical management.

MEASUREMENTS AND MAIN RESULTS

A total of 44,981 TBAD patients were included, of whom 5421 (12%) were managed at a nonteaching (NT) hospital and 39,470 (88%) were treated at a teaching (T) hospital. Propensity score matching (1:1) yielded 4676 matched pairs. In-hospital mortality (12.9% for NT vs 12.5% for T; p = 0.58) and 30-day readmission (23.3% for NT vs 21.8% for T; p = 0.12) outcomes were not statistically significantly different between the groups. On multivariable regression, teaching status was not associated with higher odds of in-hospital mortality (odds ratio [OR], 0.943; 95% confidence interval [CI, 0.841-1.057; p = 0.31) or 30-day readmission (OR, 0.965; 95% CI, 0.88-1.058; p = 0.44). At teaching hospitals, TEVAR was associated with higher odds of in-hospital mortality (OR, 1.898; 95% CI, 1.596-2.257; p < .01), while hospital volume was associated with higher odds of 30-day readmission (quartile 3: OR, 1.488; 95% CI, 1.106-2.002; quartile 4: OR, 1.684; 95% CI, 1.256-2.257; p < 0.01).

CONCLUSIONS

Hospital teaching status alone was not associated with in-hospital mortality or 30-day readmission in TBAD patients. At teaching hospitals, management by TEVAR and greater hospital volume were associated with in-hospital mortality and 30-day readmission outcome, respectively.

Acute Aortic Dissection After Transcatheter Aortic Valve Replacement

Acute aortic dissection (AAD) is a rare and potentially fatal complication associated with transcatheter aortic valve replacement (TAVR). Owing to the paucity of existing institutional data, we sought to assess the incidence of postimplant AAD in patients who underwent TAVR at a single institution. All patients who underwent TAVR from 2013 to 2022 were retrospectively reviewed to identify those who possessed clinical or radiologic evidence of AAD after TAVR. Follow-up and survival data were retrieved for all included patients. A total of 4,317 patients underwent TAVR, of whom 9 (0.2%) sustained an AAD. These patients had a mean age of 80 years (range 53 to 92), mean Society of Thoracic Surgeons 30-day mortality risk of 5.7% (2.4% to 16.7%), and mean effective aortic valve area of 0.8 cm2 (0.4 to 1.5 cm2). Preoperative maximum aortic diameter was 3.9 cm (2.6 to 4 cm). Of these 9 patients, 6 (67%) showed evidence of Stanford type A dissection, whereas 3 (33%) were diagnosed with Stanford type B dissection. The most common causes of dissection were posterior annular rupture by the transcatheter valve (THV) (44%) and THV embolization or "pop-out" into the ascending aorta (22%). A total of 6 patients (66.7%), comprising 5 type A (55.6%) and 1 type B (11.1%) aortic dissections, died within 30 days of AAD. The median time to follow-up in those surviving TAVR with intraoperative AAD was 1,042 days (range: 648 to 2,666). Surviving patients were managed through thoracic endovascular aortic repair and medical management. In conclusion, in this highly selected cohort of patients, our experience indicates that AAD after TAVR is a rare but often lethal intraprocedural sequela of THV implantation, especially in cases of type A aortic dissection.

Clinical outcomes and aortic remodeling after Castor single-branched stent-graft implantation for type B aortic dissections involving left subclavian artery

Background

The left subclavian artery (LSA) can be intentionally covered by a stent graft to acquire adequate landing zones for a proximal entry tear near the LSA during thoracic endovascular aortic repair (TEVAR). The Castor single-branched stent graft is designed to treat type B aortic dissection (TBAD) to retain the LSA during TEVAR. This study investigates clinical outcomes, aortic remodeling, and abdominal aortic perfusion patterns after TEVAR with the novel Castor device.

Methods

From November 2020 to June 2023, 29 patients with TBAD involving the LSA were treated with the Castor single-branched stent graft. In-hospital clinical outcome and aortic computed tomography angiography (CTA) data were analyzed. CTA was performed preoperatively and at follow-up to observe stent morphology; branch patency; endoleak; change in true lumen (TL), false lumen (FL), and transaortic diameters; and abdominal aortic branch perfusion pattern.

Results

The technical success rate was 96.6%. One failure was that the branch section did not completely enter the LSA and the main body migrated distally. No in-hospital mortality, paraplegia, or stroke occurred. During follow-up, one type Ib endoleak, four distal new entry tears, and one recurrent type A dissection arose from a new entry tear at the ascending aorta, no stent migration was observed, and the branch patency rate was 100%. At the thoracic aorta, TL diameters significantly increased, FL diameters markedly decreased, and FL was partially or completely thrombosed in most patients at follow-up. At the abdominal aorta, we observed 33.3% of TL growth and 66.7% of TL stabilization or shrinkage. The initial TL ratio at iliac bifurcation negatively predicted abdominal TL growth after TEVAR with a cutoff of 21.0%. Of the 102 abdominal aortic branches, 94.1% of the branches showed no change in perfusion pattern, 3.9% of the branches had an increased TL perfusion, and 2.0% of the branches had an increased FL contribution.

Conclusion

The Castor unibody single-branched stent graft offers an efficient endovascular treatment for TBAD involving the LSA. TEVAR with the Castor device effectively induced thoracic FL thrombosis and thoracic TL enlargement and resulted in abdominal TL growth when the initial TL ratio at iliac bifurcation is less than 21.0%. Abdominal aortic branch perfusion patterns remain relatively stable after TEVAR with the Castor stent graft.

Predicting adverse events after thoracic endovascular aortic repair for patients with type B aortic dissection

The potential of adverse events (AEs) after thoracic endovascular aortic repair (TEVAR) in patients with type B aortic dissection (TBAD) has been reported. To avoid the occurrence of AEs, it is important to recognize high-risk population for prevention in advance. The data of 261 patients with TBAD who received TEVAR between June 2017 and June 2021 at our medical center were retrospectively reviewed. After the implementation of exclusion criteria, 172 patients were finally included, and after 2.8 years (range from 1 day to 5.8 years) of follow up, they were divided into AEs (n = 41) and non-AEs (n = 131) groups. We identified the predictors of AEs, and a prediction model was constructed to calculate the specific risk of postoperative AEs at 1, 2, and 3 years, and to stratify patients into high-risk (n = 78) and low-risk (n = 94) group. The prediction model included seven predictors: Age > 75 years, Lower extremity malperfusion (LEM), NT-proBNP > 330 pg/ml, None distal tear, the ratio between the diameter of the ascending aorta and descending aorta (A/D ratio) > 1.2, the ratio of the area of the false lumen to the total aorta (FL ratio) > 64%, and acute TEVAR, which exhibited excellent predictive accuracy performance and discriminatory ability with C statistic of 82.3% (95% CI 77.3-89.2%). The prediction model was contributed to identify high-risk patients of postoperative AEs, which may serve to achievement of personalized treatment and follow-up plans for patients.