Ten Year Clinical and Aortic Remodelling Outcomes following Endovascular Repair of Chronic Type B Aortic Dissection.

OBJECTIVE: Thoracic endovascular aortic repair (TEVAR) has increasingly replaced open surgery for chronic type B aortic dissection (cTBAD) with aneurysmal degeneration. However, TEVAR may promote less aortic remodelling in the chronic phase owing to persistent false lumen patency distally, and few long term outcome data exist in this setting. This study details 10 year clinical and aortic remodelling outcomes following TEVAR for cTBAD. METHODS: This was a single centre, retrospective cohort study of patients undergoing TEVAR for cTBAD with aneurysmal degeneration of the descending thoracic aorta. Late aortic remodelling was assessed in accordance with the Society for Vascular Surgery/Society of Thoracic Surgeons TBAD reporting standards: positive remodelling was defined as a decrease in total aortic diameter, or decrease in false lumen, or expansion of true lumen diameter with no increase in total aortic diameter; negative remodelling was defined by the opposite or absence of these changes. The primary outcome was 10 year aorta specific death. Secondary outcomes were 30 day or in hospital death or major morbidity, late overall survival, freedom from re-intervention, and extent and anatomical distribution of aortic remodelling. RESULTS: One hundred and ninety-seven patients (73.1% male; median age 60.7 years [interquartile range 54.1, 68.8]) underwent TEVAR for cTBAD: 89 (45.2%) had residual TBAD following repair of DeBakey type I dissection, with the remainder having de novo TBAD. The median interval between index dissection and TEVAR was 3.2 years. The rate of 30 day or in hospital mortality was 2.5%, stroke 2.0%, new dialysis 1.0%, and permanent paraparesis or paraplegia 0.5%. At 10 years, the aorta specific mortality rate was 8%, while the overall mortality rate was 46%. Moreover, 24.9% required at least one major aortic re-intervention at a median of 1.4 years post-TEVAR, most commonly open thoraco-abdominal repair. Positive remodelling at the site of maximum pre-operative aortic diameter, typically the proximal descending thoracic aorta, was observed in 77% at 1 year and 87% at 5 years. Positive remodelling was less frequent in the distal aorta. CONCLUSION: In this institutional series, TEVAR for cTBAD yielded excellent peri-operative outcomes, with late death rarely due to aorta specific causes. However, positive remodelling was chiefly confined to thoracic zones where the endografts were deployed, and re-operations for downstream disease were frequently required.

Duke Scholars

Author George Charles Hughes IV Surgery, Cardiovascular and Thoracic Surgery

Author Chandler Alexander Long Surgery, Vascular and Endovascular Surgery

Author Christopher Jensen