Endovascular repair of acute vs. subacute uncomplicated type B aortic dissection: a systematic review and meta-analysis

Complications after treatment of type B aortic dissection with TEVAR stent-graft deployment in zone 2

OBJECTIVE

To analyze the outcome of 147 cases of type B aortic dissection with thoracic endovascular aortic repair (TEVAR).

METHODS

We systematically reviewed 147 patients of type B aortic dissection with stent graft deployment in zone 2 or zone 3 by TEVAR from January 2012 to December 2022. These patients were observed by computed tomography angiography after the first and third months and annually thereafter during follow-up. Statistical analysis was performed by SPSS.16.

RESULTS

The stent graft of 107 patients was deployed in zone 3, and the stent graft of 40 patients was deployed in zone 2. Severe dissection and surgery-related complications after TEVAR occurred in 19 patients, with complications arising more frequently in zone 2 than in zone 3 (12/40 vs. 7/107, P < 0.005). Endoleak was detected in 10 (6.8%, 10/147) cases, which included 6 cases of endoleak in zone 2, exceeding the 4 cases of endoleak in zone 3 (6/40 vs. 4/107, P < 0.05). Twelve (8.16%, 12/147) cases underwent re-intervention, and the 8 patients who underwent re-intervention in zone 2 exceeded the 4 patients who underwent re-intervention in zone 3 (8/40 vs. 4/107, P < 0.05). One case of subclavian steal in zone 2 (0.68%, 1/147). Two (1.36%, 2/147) cases died after TEVAR. The 1-year, 3-year, and 5-year overall survival rates were 99.3%, 98.6%, and 98.6%, respectively. The re-intervention rates were 5.4%, 7.5%, and 8.2%, respectively. The re-intervention rates in zone 2 were 15%, 20%, and 20%, respectively. The re-intervention rates in zone 3 were 1.9%, 2.8%, and 3.7%, respectively.

CONCLUSION

TEVAR is the major treatment to use if the stent graft can be deployed in zone 3. However, with the higher rate of complications and re-intervention after TEVAR, for patients whose stent graft can only be deployed in zone 2, it is not recommended that TEVAR be chosen as the preferred treatment.

Questions and Certainty in Diagnosis and Management of Acute Type B Aortic Dissection

Type B aortic dissection (TBAD) is a severe cardiovascular condition that requires timely diagnosis and intervention to prevent life-threatening complications. The aim of this review was to focus on the most crucial and controversial aspects of contemporary TBAD management. It is recognized that in the acute phase, computed tomography angiography (CTA) plays an essential role in evaluating the extent of the dissection and monitoring disease progression. CTA has significantly improved the management of TBAD by providing detailed assessments of aortic anatomy and dynamic flow changes, positioning it as the cornerstone imaging modality for identifying acute high-risk patients who may require early intervention. Recently, new advances in magnetic resonance imaging (MRI) and positron emission tomography (PET) technology have the potential to provide further information beyond imaging alone. However, such sophisticated techniques should be reserved for stable patients after the acute phase. After decades of medical therapy and high risk surgery, thoracic endovascular aortic repair (TEVAR) has emerged as a minimally invasive alternative to open surgery for complicated TBAD, offering lower perioperative morbidity and mortality. Nevertheless, its use in uncomplicated TBAD remains a topic of ongoing debate. While recent studies suggest that preemptive TEVAR combined with optimal medical therapy may reduce late adverse events and improve long-term outcomes, these findings remain controversial. This review critically analyzes the current literature on both diagnosis and TEVAR treatment, evaluating these controversies in the context of clinical practice.

Optimal Timing of Pre-emptive Thoracic Endovascular Aortic Repair in Uncomplicated Type B Aortic Dissection: A Network Meta-Analysis

BACKGROUND

This network meta-analysis compares outcomes of optimal medical therapy (OMT) and pre-emptive thoracic endovascular aortic repair (TEVAR) for uncomplicated type B aortic dissection at different phases of chronicity.

METHODS

MEDLINE and EMBASE were searched through November 2023. Pooled short-term outcomes (short-term mortality, perioperative complications) and long-term outcomes (all-cause mortality, aortic-related mortality, aortic re-intervention rates) were calculated.

RESULTS

Systematic review identified 17 studies (2 randomized controlled trials, 3 propensity score matching, and 2 inverse probability weighting). Subacute-phase intervention had lower short-term mortality than the acute-phase (hazard ratio [HR] [95% confidence interval [CI]]=0.60 [0.38-0.94], p=0.027). No significant differences were observed in aortic rupture and paraplegia. Acute-phase TEVAR had a higher stroke incidence than subacute-phase intervention (HR [95% CI]=2.63 [1.36-5.09], p=0.042), chronic (HR [95% CI]=2.5 [1.03-6.2], p=0.043), and OMT (HR [95% CI]=1.57 [1.12-2.18], p=0.008). Acute-phase TEVAR had higher long-term all-cause mortality than subacute-phase intervention (HR [95% CI]=1.34 [1.03-1.74], p=0.03). Optimal medical therapy had elevated long-term all-cause mortality compared with subacute-phase TEVAR (HR [95% CI]=1.67 [1.25-2.33], p<0.001) and increased long-term aortic-related mortality vs acute-phase (HR [95% CI]=2.08 [1.31-3.31], p=0.002) and subacute-phase (HR [95% CI]=2.6 [1.62-4.18], p<0.01) interventions. No significant differences were observed in aortic re-intervention rates.

CONCLUSIONS

Pre-emptive TEVAR may offer lower all-cause mortality and aortic-related mortality than OMT. Considering lower short-term mortality, perioperative stroke rate, and long-term mortality, our findings support pre-emptive TEVAR during the subacute phase.

CLINICAL IMPACT

The optimal timing of pre-emptive thoracic endovascular aortic repair (TEVAR) for uncomplicated type B aortic dissection remains uncertain. This network meta-analysis suggests that the subacute phase (14-90 days from symptom onset) emerges as the optimal timing for pre-emptive TEVAR. This window is associated with lower rates of short-term complications and higher long-term survival rates compared with alternative strategies.