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Aortic remodeling after TEVAR for acute complicated type B aortic dissection
Ryan Bishop, BS, Daniel Ocazionez-Trujillo, MD, Kristofer Charlton-Ouw, MD, Rana Afifi, MD, Harleen Sandhu, MD, Samuel Leake, BS, Naveed Saqib, MD, Maria Codreanu, MD, Sheila Coogan, MD, Charles Miller, PhD, Anthony Estrera, MD, Hazim Safi, MD, Ali Azizzadeh, MD.
The University of Texas at houston Medical School, Houston, TX, USA.
Background:
Thoracic endovascular aortic repair (TEVAR) is a treatment option for patients with acute complicated type B aortic dissection (ACTBAD). The optimal extent of aortic coverage during TEVAR is not well defined. Our current practice involves coverage of the proximal entry tear with a single device. The purpose of this study was to evaluate aortic remodeling after TEVAR for ACTBAD.
METHODS:
We reviewed TEVAR patients with ACTBAD between 2006-2014. The diameter, total aortic area, true lumen (TL), and false lumen (FL) were measured at six locations (1. left subclavian, 2. pulmonary artery, 3. left atrium, 4. celiac, 5. lower renal artery, 6. infrarenal aorta). A specialized radiologist obtained measurements using 3D software (TeraRecon, Fostercity, CA). Differences in diameter and area were computed and transformed to relative frequency (percent change from baseline). Percent change was analyzed in its native distribution and as distribution-free rank variables. Data were analyzed by linear multilevel model, using MIXED procedure in SAS 9.3 (SAS Institute Inc., Cary, NC).
Results:
During the study period, 44 patients (median age of 64.5, 73% male) underwent TEVAR for ACTBAD. The 30 mortality, stroke, and paraplegia was (20.5%, 4.55%, 18.2%) respectively. Seventeen patients who had complete imaging datasets were included in the study. The mean extent of aortic coverage was 19.8 cm. Total aortic diameter was not changed by TEVAR at any location (p=0.78). TL diameter and area were increased by 100% and 150%, respectively, at locations 2 and 3 (p<0.005). FL diameter and area were reduced by 50% percent each at locations 1 and 3 (p<0.04). Luminal diameters beyond the stent-graft were unchanged. The FL was thrombosed over the treated segment in 70% while the FL was patent in the untreated segment of the aorta in 100%. The median time for follow-up imaging was 36 days (IQR 17-48).
Conclusion:
Aortic remodeling occurred as expected in the segments covered by the stent-graft, but distal segments were unchanged. This raises the question of whether exclusion of the proximal entry tear alone is sufficient, or whether extension of coverage is necessary. Long-term studies are indicated to determine the optimal length of coverage. 
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