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Ann Thorac Surg 1996;61:1339-1341
© 1996 The Society of Thoracic Surgeons

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Original Articles: Cardiovascular

Selective Management of Acute Type B Aortic Dissection: Long-Term Follow-up

Department of Cardiothoracic Surgery, Mount Sinai Medical Center, New York, New York

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Background.Since 1985, we have selectively treated acute type B aortic dissections. Initial treatment lowered blood pressure and heart rate. Transesophageal echocardiography and computed tomographic scans were used to diagnose and follow up the patients. Patients were operated on for organ ischemia, pain, hypertension, or increasing subpleural fluid on computed tomographic scan.

Methods.We retrospectively reviewed consecutive patients admitted over a 10-year period to the Mt. Sinai Hospital.

Results.From August 1985 to May 1995, 68 patients were seen. Three died soon after admission during initial diagnostic evaluation. Seventeen patients underwent operation without mortality or paraplegia (group 1). Forty-seven of 48 patients treated nonoperatively were discharged; 1 patient died of rupture on day 7 (group 2). Actuarial survival for all 68 patients at 1 and 5 years was 92% plusmn; 4% and 82% plusmn; 8%. Group 1 survival was 93% plusmn; 4% and 68% plusmn; 5%, and group 2 survival was 90% plusmn; 6% and 87% plusmn; 14%. There were no differences between groups. Late intervention was required in 2 group 1 patients (12%) and in 12 of 48 group 2 patients (25%), again without mortality or paraplegia.

Conclusions.This experience suggests that selective management of acute type B aortic dissection results in acceptable short-term and long-term survival. Avoiding early operation did not compromise late results.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
See also page 1341.

The benefit of urgent operation for acute type A aortic dissection is established, but the management of acute type B dissection remains controversial. Since 1985, we have treated 68 patients with acute type B dissection, selectively recommending early operation or medical management. The present study is a retrospective review of these cases, reporting our selection criteria, with early and long-term outcomes.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
We examined all case records for acute (less than 2 weeks) type B aortic dissection treated at The Mount Sinai Hospital since 1985. The review identified 68 patients, 42 male and 26 female, with ages ranging from 32 to 96 years (mean, 65.5 years). Type B dissection was diagnosed by angiography, computed tomographic (CT) scan, magnetic resonance imaging, transesophageal echocardiography, or a combination of these. Since 1990, transesophageal echocardiography was our diagnostic method of choice, and angiography has not been used. Discharged patients were enrolled in a follow-up program, periodically monitoring their progress; CT scans were repeated at 6 months and then yearly. Follow-up ranges from 0 to 112 months (mean, 31 months). Medical therapy consisted of aggressive antihypertensive and ``antiimpulse'' therapy. Patients with unremitting pain or uncontrollable hypertension despite this regimen underwent early operation. Urgent operation was also performed for rupture or significant aortic dilatation (greater than 5 cm). Recently, malperfusion, initially an indication for operation, has been relieved using percutaneous catheter fenestration [1–3]. Patients assigned to medical therapy underwent surveillance CT scans at 48 hours, at 7 days, and during the hospital course as deemed necessary. Based on serial CT scans, operation was recommended for increasing periaortic or intrapleural fluid extravasation, rapid aortic expansion, or significant aortic dilatation.

The surgical technique involved sequential intercostal artery interruption with somatosensory evoked potential monitoring, spinal fluid drainage, and corticosteroid administration and has been described in detail [4]. Perfusion was monitored with transesophageal echocardiography during the procedure to prevent intraoperative iatrogenic malperfusion syndrome [5, 6]. Attempts were made to resect intimal tears, but generally resection was limited to the upper and middle thoracic aorta. Normal flow was restored by reapproximating the true and false lumen distally before performing the distal anastomosis.

For analysis, patients were separated into two groups based on initial therapy. Group 1 includes 17 patients having early operation, and group 2 includes 48 patients initially assigned to medical management. Three patients died during initial evaluation. One, a 96-year-old woman, was hypotensive upon presentation, and the diagnosis was made postmortem. The other two patients died during angiography and shortly after CT scan but before surgical evaluation, respectively. Aorta-related events included operation (aortic replacement or femorofemoral bypass) or percutaneous catheter fenestration. Fenestration has been used preferentially over femorofemoral bypass for leg ischemia since its availability in 1993.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Mortality
Hospital mortality for group 1 and group 2 was 0% and 2%, respectively.

Survival
Actuarial survival for all 68 patients was 92% plusmn; 4% at 1 year and 82% plusmn; 8% at 5 years (Table 1). The 1-year and 5-year survival rates were 93% plusmn; 6% and 68% plusmn; 14%, respectively, for group 1 and 96% plusmn; 3% and 93% plusmn; 4% for group 2. The apparent difference in late survival between groups was not statistically significant by Mantel-Cox comparison of survival curves. Event-free 1-year and 5-year survival for group 1 (93% plusmn; 6% and 56% plusmn; 16%) and group 2 (84% plusmn; 6% and 64% plusmn; 10%) did not differ by Mantel-Cox analysis.

Group 2 (Medicine)
Of 48 patients assigned to medical therapy, only 1 patient (2%) died of aortic rupture (on hospital day 7). However, 12 patients (25%) required aorta-related interventions. Three patients required intervention for malperfusion. Two patients underwent percutaneous transluminal fenestrations in the acute phase for leg and renal ischemia, and 1 required late femorofemoral bypass for progressive leg ischemia. Nine patients required resection for dilation or progressive symptoms. One patient who underwent percutaneous fenestration had temporary renal and respiratory insufficiency, but otherwise there were no major complications for the 12 patients. Respiratory insufficiency complicated the course of 2 (4%) of the 35 survivors not requiring intervention. Forty-seven patients (98%) were discharged to home. There were two late deaths (4%); one due to pulmonary embolus at 4 months and one due to aortic rupture at 19 months after diagnosis.

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
In contrast to other recent reports [7–12], we found no difference in overall survival between surgically and medically treated patients. Both hospital mortality and actuarial survival had improved. As we are a tertiary referral center, many of our patients are self selected, having survived early screening and treatment. The 3 patients who died during diagnostic workup were all first seen at our institution.

Importantly, survival is better because of recent improvements in both modalities for managing acute type B aortic dissection. Rapid diagnosis, intensive monitoring, and aggressive modern pharmacologic management have advanced medical treatment. Newer imaging modalities, especially transesophageal echocardiography, improved CT scanning (including spiral CT), and magnetic resonance imaging angiography have made diagnosis faster and more accurate, allowing for earlier treatment. Technologic advancements like percutaneous transluminal aortic fenestration has also allowed for better nonoperative management. Better preoperative, intraoperative, and postoperative care have reduced surgical mortality as well. Preoperative care is better for the same reasons medical treatment is better. Patients often arrive in the operating suite in more stable condition. Intraoperative care is better as our experience and understanding has grown. Many new adjuncts to spinal cord preservation such as somatosensory evoked potential monitoring and sequential intercostal interruption [4], as well as pharmacologic measures like mannitol and steroids before cross-clamping, have all decreased paraplegia. Collagen-impregnated grafts have further reduced operative bleeding. Postoperative spinal drainage and intensive monitoring have decreased perioperative complications and mortality.

Once patients leave the hospital (whether operated on or not) aggressive follow-up begins. In a 20-year follow-up study DeBakey and associates [13] found blood pressure control was critical in determining late aneurysm formation in these patients, with 17% of those with good control and 45% of those with poor control having aneurysmal degeneration. Strict blood pressure control is the mainstay of our outpatient management and frequent CT scanning allows early, elective intervention when necessary.

The important considerations in examining surgical treatment are the early surgical mortality and complication rate, and the risk of medical therapy with subsequent operation. Miller's group [11] has been a proponent of early operation, especially if surgical and medical treatment give similar mortalities. The major complication rate of 59% in the early surgical group makes this option less desirable. Our data further show that late operation, when necessary, can be performed safely. There were no deaths, paraplegia, or major complications in these patients. Moreover, selective management is the major reason mortality is low and survival is good. This is further supported by the fact that there was only one aorta-related death in the 64 patients discharged home.

In conclusion, over 10 years, 68 patients with acute type B aortic dissection were selectively managed with medical or surgical therapy. The described selection criteria resulted in acceptable short-term and long-term survival for both groups, with no difference in survival or event-free survival between groups.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Presented at the Forty-second Annual Meeting of Thoracic Surgical Association, San Antonio, TX, Nov 9-11, 1995.

Address reprint requests to Dr Schor, Department of Thoracic and Cardiovascular Surgery, Mount Sinai Medical Center, 4300 Alton Rd, Suite 211, Miami Beach, FL 33140.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 

1. Saito S, Arai H, Kim K, Aoki N, Tsurugida M. Percutaneous fenestration of dissecting intima with a transseptal needle. A new therapeutic technique for visceral ischemia complicating acute aortic dissection. Cathet Cardiovasc Diagn 1992;26:130–5.[Medline]
2. Faykus MH Jr, Hiette P, Koopot R. Percutaneous fenestration of a type I aortic dissection for relief of lower extremity ischemia. Cardiovasc Intervent Radiol 1992;15:183–5.[Medline]
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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): John S. Schor Jan D. Galla Steven L. Lansman Randall B. Griepp Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Schor, J. S. Articles by Griepp, R. B. Search for Related Content PubMed PubMed Citation Articles by Schor, J. S. Articles by Griepp, R. B. Related Collections Related Article