With proper patient selection, short-term outcomes of thoracic endovascular aortic repair (TEVAR) in acute uncomplicated acute type B aortic dissection (uTBAD) are similar irrespective of the timing of treatment after dissection. This is according to a study recently published in the Journal of Vascular Surgery (JVS).
Authors Adam W Beck (University of Alabama at Birmingham, Birmingham, USA) and colleagues write in their introduction that the timing of TEVAR after the onset of uTBAD “remains controversial”. The objective of the present study, against this backdrop of contention, was to evaluate the Society for Vascular Surgery (SVS) Vascular Quality Initiative (VQI) post-approval study (VQI PAS) data for the impact of TEVAR timing for uTBAD on early and late outcomes. These included mortality, procedural complications, and long-term reintervention.
The investigators note that the VQI PAS used for this analysis includes a total of 606 patients. Those patients with uTBAD—who were defined as those without rupture or malperfusion—exclusive of cases categorised as emergency (n=206), were divided into groups defined by the SVS/Society of Thoracic Surgeons reporting guidelines based on the timing of treatment after the onset of dissection. The three groups were: treatment within 24 hours (n=8), between one to 14 days (n=121) and between 15 to 90 days (n=77). The researchers used univariate and multivariable analysis to determine differences between timing groups for postoperative mortality, in-hospital complications and reintervention.
Demographics and comorbid conditions were “very similar” across the three TEVAR timing groups, Beck et al detail. The authors state that there were some “notable differences” between the groups, including higher prevalence of baseline elevated creatinine (>1.8mg/dL)/chronic end-stage renal disease and designation as ‘urgent’ in the <24-hour group, as well as a higher rate of preoperative ß-blocker therapy in the one- to 14-day group.
The authors report that postoperative stroke, congestive heart failure and renal ischaemia were more common in the <24-hour group without an increase in mortality. Unadjusted 30-day mortality across the groups, they continue, was lowest in the early TEVAR group (0%, 3.3% and 5.2%; p=0.68), as was the one-year mortality (0%, 8.3% and 18.2%; p=0.06). However, they add the caveat that these results were not statistically different at any time point.
Furthermore, Beck and colleagues reveal that reintervention out to three years was not different between the groups, and that multivariable analysis demonstrated the need for a postoperative therapeutic lumbar drain to be the only predictive risk factor for mortality (hazard ratio=7.595, 95% confidence interval: 1.73–33.337, p=0.007).
In the conclusion of their study, Beck et al acknowledge that patients with uTBAD treated within 24 hours were unusual (n=8) and the group was “too small for valid statistical comparison”. They add that these patients “likely represent a high-risk subgroup, which is manifested in a higher risk of complications”.
Although there was a “trend” toward improved survival in the acute (one- to 14-day) phase, the researchers summarise that outcomes did not differ compared with the subacute (15- to 90-day) phase with relation to early mortality, postoperative complications, or one-year survival. They state in closing: “These data suggest that the proper selection of patients for early TEVAR can result in equivalent survival and early outcomes.”