Early Outcomes after Emergent Endovascular Management of Complex Acute Type III/B Aortic Dissections

Background: Surgical management of complicated acute Type B aortic dissection is associated with significant morbidity and mortality. The purpose of this study is to examine the feasibility and safety of endovascular treatment of this pathology.
Methods: We reviewed a prospectively maintained TEVAR database and medical records at a single institution from 2000-2007. Acute Type B dissection was defined as symptoms ≤14 days of presentation. All 30-day or in-hospital outcomes were reported.
Results: 23 (8.7%) of 265 TEVAR were emergently performed for acute Type B dissections complicated by rupture and/or malperfusion using the TAG device. The mean age of the dissection group was 65±13 years with 7 (30%) females, both similar to the overall cohort (67±27 years and 32%, p=NS). The average duration of symptoms was 2.6±3.5 (median, 1) days. The indications for repair included rupture in 12 patients (52%) and mesenteric/renal/lower extremity ischemia in 11 (48%). Fluoroscopy (31±18 vs. 22±12 min, p=0.001) and contrast use (169±53 mL vs. 129±46 mL, p<0.0001) were both significantly higher for the dissection group than for the overall TEVAR cohort. 8 (73%) of 11 patients with malperfusion required adjunctive branch vessel stenting, while only 1 (8%) of the 12 ruptured patients had any additional endovascular therapy beyond their endograft repair. Perioperative mortality was 23% (5 of 22), which was significantly higher than that of the remaining TEVAR group (4.5%, p=0.007). Severe complications included respiratory failure requiring tracheostomy (5, 23%), permanent spinal cord ischemia (5, 23%), renal failure requiring dialysis (3, 13%), and stroke (3, 13%). Of the 23 patients, 83% had at least one major complication. Their mean postoperative LOS was 18.3±18.7 days (overall group, 7.4±10.8 days, p<0.0001), and only 8 (35%) were able to be discharged home.
Conclusions: Emergent endovascular repair of complicated acute Type B dissections is associated with significant mortality and morbidity, which are both higher than endovascular treatment of other thoracic aortic diseases. The overall role of this therapy in the treatment of this lethal problem remains to be defined.