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Ann Thorac Surg 2008;86:1707-1712. doi:10.1016/j.athoracsur.2008.06.074
© 2008 The Society of Thoracic Surgeons
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Review

Outcome of Endovascular Treatment of Acute Type B Aortic Dissection

Jun D. Parker, Jonathan Golledge, MChir*

Vascular Biology Unit, School of Medicine, James Cook University, Townsville, Australia

* Address correspondence to Dr Golledge, Vascular Biology Unit, Department of Surgery, School of Medicine, James Cook University, Townsville, QLD, 4811, Australia (Email: jonathan.golledge{at}jcu.edu.au).


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 Acknowledgments
 References
 
Complicated type B aortic dissection is a life-threatening condition. For the last decade, endovascular stent-graft placement has been increasingly used to treat this condition. We undertook a summary analysis of published studies reporting the outcome of stent-grafts to treat complicated type B dissection. Studies were identified from a literature search using the MEDLINE database, and included studies when 10 or more patients were reported and at least in-hospital mortality was presented. A total of 942 patients were included from 29 studies. All patients were reported to have complications requiring intervention (hypotension in 17%). In-hospital mortality was 9% and other major complications (ie, stroke, paraplegia, conversion to type A dissection, bowel infarction, major amputation) occurred in 8.1%. Long-term follow-up was limited to a mean of 20 months. During this time, reintervention was required in 10.4% and aortic rupture was reported in 0.8%. Endovascular treatment of complicated acute type B aortic dissection seems to provide favorable initial outcomes and would seem to be a great addition to the treatment options for this condition. Further study of long-term outcomes is required.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 Acknowledgments
 References
 
Acute aortic dissection affects approximately 3 per 100,000 persons per year [1]. Dissection not involving the ascending aorta (type B) is usually treated medically in the first instance; however, when complications, such as aortic rupture, peripheral malperfusion, or uncontrollable hypertension develop, surgical treatment is considered [2]. For the last decade there has been increasing interest in treating such patients by endovascular placement of covered stents over the entry point of the dissection [2]. Two recent reviews have reported the outcome of endovascular treatment of aortic dissection [3, 4]. Both reports included patients with acute and chronic dissection for which the outcomes and indications for intervention are different [3]. In addition, the appropriateness of endovascular treatment for chronic aortic dissection has been questioned due to the established nature of the false lumen and the presence of multiple fenestrations that make the stimulation of false lumen thrombosis unlikely [2]. In this report, we have presented results on the use of endovascular repair for acute aortic dissection to provide a contemporary summary of the outcome in these patients.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 Acknowledgments
 References
 
Study Selection
Using the keywords "acute," "aortic," "dissection," "aortic syndrome," and "endovascular," a comprehensive search was conducted using the MEDLINE database. We also searched reference lists of identified publications. We sought studies in which patients with acute type B aortic dissection were treated by endovascular stent-grafts. To keep findings contemporary; we only included studies published between 1997 and 2007. There were 148 identified articles; and the abstracts were initially reviewed. To include centers with experience in the technique; we limited entry to studies including a minimum of 10 patients with acute type B aortic dissection that were treated by endovascular placement of a stent-graft. The minimum outcome data required for the study to be included was in-hospital mortality. Articles on traumatic type B dissection were excluded. Based on these entry and exclusion criteria; 29 articles were included [5–33].

Data Extraction
The 29 articles selected were scrutinized to extract 34 pre-defined variables with regard to patient demographics, co-morbidities, complications at presentation, and postoperative short-term and long-term outcomes [5–33]. These variables were indications for intervention; number of patients with acute type B dissection treated; mean age; proportion of subjects who were male and had a prior history of Marfan's syndrome, hypertension, aortic aneurysm, diabetes mellitus, cardiac surgery or catheterization; preoperative variables suggesting complications of the aortic dissection, including systolic blood pressure > 150 mm Hg, systolic blood pressure < 100 mm Hg, paraplegia, acute stroke, visceral ischemia, renal insufficiency, and leg ischemia; type of stent-graft; procedural success; emergency conversion to open surgery; complete false lumen thrombosis; in-hospital complications, including mortality, stroke, paraplegia–paresis, bowel infarction, major amputation, renal insufficiency requiring dialysis, and retrograde type A dissection development; mean patient follow-up; and late complications, including late mortality, survival, aortic rupture, reintervention by endovascular or open surgical means. Data extraction was carried out independently by both authors, and discrepancies were resolved by discussion with mutual consensus. Major in-hospital short-term complications, such as emergency conversion, paraplegia, stroke, renal failure needing dialysis, major amputation, type A dissection development, and bowel infarction were assumed to have been stated in the article if they had occurred where the authors specifically included a section on postoperative complications. For other variables, when they were not clearly stated in the articles, they were considered to be unavailable. No additional data was provided by the authors.

Definitions
Acute type B aortic dissection denoted dissection confined to the descending aorta and presentation within 14 days from the onset of symptoms. Procedural success indicated successful stent-graft deployment at the intended site without emergency conversion to open surgery to correct aortic complications. Preoperative stroke was classified into acute and chronic. Acute denotes concomitant stroke at presentation as a direct complication from the dissection. Chronic denotes a past history of stroke.

Analysis
A number of studies presented combined data on a number of pathologies other than acute type B dissection. In a few instances the data presented in these articles was only available for the combined patient group. In these instances, weighted numbers were calculated for the variables in question. After data collection, initial assessment was carried out. Variables with data only available in less than 30% of the total number of studies were excluded from the final analysis and presentation. This amounted to exclusion of eight variables (ie, prior history of Marfan's syndrome, cardiac catheterization, aortic aneurysm, diabetes mellitus, cardiac surgery, the preoperative complication systolic blood pressure > 150 mm Hg, visceral ischemia, and paraplegia. For other data fields, the extracted variables were used to calculate weighted means for the total series of patients.


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 Acknowledgments
 References
 
Preoperative Patient Characteristics
From the total of 148 studies, 29 met the inclusion criteria and were selected for data extraction [5–33]. Three of these studies included more than 100 patients each and contributed 40% of the total of 942 patients [18, 28, 31]. The presenting characteristics of the patients are illustrated in Table 1. The mean age was relatively young at 61 years and the majority of patients were male with a prior history of hypertension. Hypotension, renal impairment, and leg ischemia were relatively common at presentation (Table 1). On the contrary, neurologic complications were rare at presentation with only 0.4% of patients presenting with acute stroke. In all studies in which the indications for intervention were clearly stated, only patients with complications such as aortic rupture, impending rupture, peripheral malperfusion, uncontrolled hypertension, or refractory pain were treated. The anatomical criteria stated varied from a landing zone with a diameter < 38 to < 44 mm and length > 5 to > 10 mm [11, 21, 27, 29]. Most stated that suitable access arteries were required for the entry sheath.


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  		Table 1 Preoperative Patient Characteristics
 
Initial Outcomes
The early postoperative patient outcomes including the reported in-hospital complications are shown in Table 2. Technical success was achieved in 95% of cases. Although most authors reported technical success rates of 100%, a few large studies reported lower success rates that had a major influence on the overall technical success rate. Emergency surgical conversion was only necessary in 0.6%. In-hospital mortality rate was 9%. Major complications were uncommon after the procedure, the most common of which was stroke occurring in 3.1% of patients. Importantly, development of a type A dissection was noted at the time of treatment of the type B dissection or later during the hospital admission in 2% of patients. Paraplegia occurred in 1.9% of patients. Dialysis was required in 2.1% of patients during their hospital admission. Bowel infarction occurred in 0.9%, and major amputation in only 0.2%.


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  		Table 2 Postoperative Early Patient Outcomes
 
Late Postoperative Patient Outcomes
Patients were followed-up for a mean of 20 months. Average survival at this time was 88% (Table 3). Late aortic rupture was reported in only 0.8%. Reintervention rates by endovascular and surgical means were reported separately in all but two studies [14, 23]. Endovascular reintervention was more frequently required, being performed in 7.6% of patients while surgical reintervention was required in 2.8% of patients.


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  		Table 3 Postoperative Late Patient Outcomes
 

   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
Acknowledgments
 References
 
We believe that this is the first study that summarizes the current outcomes of endovascular stent-graft treatment particularly focusing on patients with acute type B aortic dissection. Two previous reviews have reported the combined results of both acute and chronic type B dissection, and in one of these studies a sub-analysis was presented on patients with acute dissection [3, 4]. Compared with these reports, we focused on acute dissection alone, included only articles with larger number of patients (≥10), and also included more recent studies [5–9].

Traditionally, the mainstay of treatment for acute type B aortic dissection has been antihypertensive medical therapy especially for uncomplicated dissection [2, 34]. For patients with evidence of impending aortic rupture or malperfusion associated with type B dissection, surgical treatment is usually considered [2, 34]. The outcome of open surgery in such patients is not favorable as would be expected from the dire situation at that stage [35]. In a recent report from the International Registry of Acute Aortic Dissection (IRAD), 82 of 476 (17%) patients with type B dissection were treated with open surgery [35]. In-hospital mortality for these patients was 29%, and new neurologic deficits occurred in 23% of patients (ie, stroke, 9%; coma, 8%; and paraplegia, 5%, and unstated neurological complication, 1%). The introduction of an endovascular approach offers a number of potential advantages in comparison with open surgical repair, including absence of aortic cross clamping, reduced blood loss, avoidance of lung collapse, and more rapid procedural time [33]. Thus, it might be expected that endovascular repair would produce more favorable outcomes. At present no randomized trials have compared open surgery and endovascular repair for complicated type B dissection. It seems unlikely that such a trial will occur for a number of reasons, including the emergency nature of the problem, the fact that many patients or specialists may be unwilling to consider both very different procedures, and some patients are only suitable for one or the other approach (eg, due to anatomical reasons, such as the extent of the dissection and proximal landing zone). In the absence of such a trial, we were interested in reporting the outcomes of endovascular repair carried out as specialist centers for the complications of acute type B dissection.

Our summary analysis suggests that when carried out at centers with experience of this technique (having treated at least 10 patients), the initial outcomes of endovascular therapy of acute type B are favorable by comparison with the surgical results reported in IRAD (Table 2). In-hospital mortality was under 10%, and other major complications, such as stroke, paraplegia, conversion to type A dissection, bowel infarction, and major amputation occurred in 8%. Of course comparison with surgical outcomes, such as those reported by IRAD has inherent problems. In the absence of randomization, there is no way of knowing that the patients are comparable. The preoperative condition of the patient is very important in determining the outcome of any surgical intervention. One of the most important predictors of outcome after open surgical treatment of complicated type B dissection is the degree of shock [35]. It might be expected that specialists and patients would be more willing to undertake treatment by endovascular compared with open intervention prior to clear signs of aortic rupture, such as shock, given the less invasive nature of endovascular repair. Unfortunately many of the studies identified in this summary analysis did not report the incidence of shock in patients with acute type B dissection (Table 1). In studies where hypotension was reported, a mean of 17% had signs of shock. For the patients reported in IRAD who underwent open surgery, 30% had signs of shock prior to commencing surgery. Such likely differences in patients selected for the two different treatments options should be kept in mind when making any comparisons between the reports of the two approaches.

One of the concerns with endovascular therapy for dissection is that it may only provide initial protection from aortic rupture [33]. The long-term follow-up of patients presented in most of the studies reported in this review is limited (ie, mean, 20 months; range, 8 to 48 months). Within this time scale, survival and reported aortic rupture rates were favorable (Table 3). Approximately 10% of patients required reintervention, mostly by endovascular means. Clearly longer follow-up times are required to assess the outcome of this approach.

In conclusion, this summary analysis suggests that endovascular treatment of complicated acute type B aortic dissection produces favorable initial outcomes and would seem to be a great addition to the treatment options for this condition. Further study of long-term outcomes is required.


   Acknowledgments
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Acknowledgments
References
 
Research undertaken by Dr Golledge is funded by the National Institutes of Health (No. RO1 HL080010-01), NHMRC, Australia (Project Grant No. 379600, Fellowship No. 431503), and NHF, Australia.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Acknowledgments
 References
 

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