Contemporary Results After Early Thoracic Endovascular Aortic Repair for Complicated and Uncomplicated Type B Aortic Dissection

The use of thoracic endovascular aortic repair (TEVAR) to treat patients with both uncomplicated and complicated acute type B aortic dissections (tBAd) continues to rise, yet there exists limited national data evaluating outcomes and predictors of adverse events. Therefore, we compared the presentation and clinical features of early TEVAR for complicated and uncomplicated aortic dissections as well as outcomes and survival following repair. We queried the Vascular Quality Improvement registry (2011-2022) for TEVAR cases for acute (<2 weeks) and subacute (2-12 weeks) tBAd, dichotomizing patients into uncomplicated vs complicated dissection. Complicated dissection was defined as presentation with visceral malperfusion, rupture, or rapidly increasing aortic size, with uncomplicated dissection, including all other presentations. Outcomes included postoperative morbidity and mortality, thoracoabdominal life-altering events (TALE defined as a composite of stroke, death, dialysis, or paraplegia), and 3-year survival. Risk adjusted analyses were performed using logistic regression clustering by center and Cox proportional hazard regression. Among 1749 patients treated for acute and subacute tBAd, 775 (44%) presented with complicated dissections. Patients with complicated dissection were more likely to be male (70% vs 61%; P < .01) and older (61.3 vs 59.7 years; P < .02), with longer procedural time (150 minutes vs 115 minutes; P < .01). Complicated dissections had higher unadjusted rates of 30-day mortality (16% vs 4.4%; P < .01), spinal cord ischemia (11% vs 4.6%; P < .01), stroke/transient ischemic attack (8.9% vs 4.7%; P < .01), new dialysis (5.8% vs 1.2%; P < .01), and TALE (31% vs12%; P < .01). Furthermore, complicated dissections had lower 3-year survival (82% vs 72%; P < .01). After adjustment, complicated dissection was independently associated with higher odds of 30-day mortality (odds ratio, 2.4; 95% confidence interval [CI], 1.6-3.4]; P < .01) and postoperative complications (odds ratio, 1.9; 95% CI, 1.5-2.4; P < .01). Factors associated with increased 3-year mortality included emergency repair (HR, 2.3; 95% CI, 1.5–3.4; P < .01), preoperative dialysis (HR, 2.8; 95% CI, 1.7-4.7; P < .01), and coronary artery disease (HR, 1.7; 95% CI, 1.2– 2.4; P < .01). These data present contemporary results of TEVAR for tBAd, showing excellent outcomes as compared with prior reports of medical and operative therapy. In light of these findings, and the risk of late aortic-related mortality shown in the literature, early aggressive intervention with TEVAR remains a necessity for complicated presentation and should be strongly considered in patients with acute uncomplicated tBAd. Further analyses regarding optimal timing for TEVAR in patients with tBAd are warranted.