High Long-term Survival Seen After TEVAR for Acute Dissection
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Patients undergoing thoracic endovascular aortic repair (TEVAR) for acute complicated aortic dissection reap durable results and excellent long-term survival, according to a small, single-center study published online October 3, 2013, ahead of print in the Journal of Vascular Surgery. Moreover, although there is a frequent need for reintervention, it does not incur a mortality cost.
G. Chad Hughes, MD, of Duke University Medical Center (Durham, NC), and colleagues analyzed outcomes of 50 consecutive patients who underwent TEVAR for acute complicated type B aortic dissection at their institution between July 2005 and December 2012. Indications for TEVAR were rupture (20%), malperfusion (48%), and/or refractory pain or impending rupture (34%). The patients were followed for a median of 33.8 months, and underwent follow-up computed tomographic angiography at 1, 6, and 12 months postoperatively.
Primary technical success, defined as endograft deployment without type I or III endoleak and absence of surgical conversion or death within 24 hours, was achieved in all but 1 patient (98%). There were no deaths either in hospital or within 30 days of the procedure. Short-term complications included 1stroke, 2 cases of new-onset dialysis, and 1 instance of permanent paraparesis/paraplegia.
Three patients required additional endovascular or open procedures within 30 days of the original endovascular repair.
Seven-year Kaplan-Meier survival was 84% while aorta-specific survival was 100%.
Need for Reintervention
Positive long-term outcomes were mitigated somewhat by a reintervention rate of 26%, with a median time to first reintervention of 4.5 months. Overall, 13 patients required 17 reinterventions, due to:
- Type I endoleak (n = 5)
- Metachronous aortic pathology (n = 5)
- Persistent false lumen pressurization via distal fenestrations (n = 4)
- Type II endoleak (n = 2)
- Retrograde acute type A aortic dissection (n = 1)
However, the majority of of reinterventions (65%) were performed using endovascular or hybrid techniques, and no survival difference was seen between patients who did or did not require reintervention.
Already the Standard
According to Dr. Hughes, because the study represents the largest single-center series with the longest follow-up to date, the data provide solid evidence that TEVAR is the appropriate technique for treating patients with this condition.
“Clinical practice has already changed,” he told TCTMD in a telephone interview. “For an acute, complicated dissection, which we know now carries a very high surgical mortality, I don’t think there is anybody in whom surgery is preferred.”
However, Dr. Hughes emphasized that because the endovascular procedure is more complicated than TEVAR for aneurysm, for example, it is probably best reserved for higher-volume centers with the expertise to deal with this more complex patient population, including experience with open repair if needed.
Ongoing Surveillance
In a telephone interview with TCTMD, Philip P. Goodney, MD, MS, of Dartmouth-Hitchcock Medical Center (Lebanon, NH), stressed the importance of short- and long-term surveillance of these patients.
“This paper is reassuring in that in patients with both low-risk lesions and some with high-risk lesions, CT scans were able to identify complications that necessitated reintervention,” he said. “And it told us that these were most likely to occur in basically the first 12 to 24 months.”
According to Dr. Goodney, this underlines the need to be fastidious about imaging within the first 2 years postprocedure. However, he added, longer-term surveillance is “a bit more of a moving target” as there are concerns about recurrent radiation exposure over time, and ultrasound is not an effective imaging modality in this situation.
Source:
Hanna JM, Andersen ND, Ganapathi AM, et al. Five-year results for endovascular repair of acute complicated type B aortic dissection. J Vasc Surg. 2013;Epub ahead of print.
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Disclosures
- Drs. Hughes and Goodney report no relevant conflicts of interest.
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