Outcomes Of TEVAR For Chronic Type B Aortic Dissection In The Vascular Quality Initiative
Abhishek Devaguptapu Rao, BA/BS1, Ambar Mehta, MD, MPH1, Priya Patel, MD2, James Iannuzzi, MD3, Karan Garg, MD4, Marc Schermerhorn5, Jeffrey Siracuse, MD6, Hiroo Takayama, MD1, Virendra Patel, MD1.
1Columbia University, New York, NY, USA, 2Rutgers-Robert Wood Johnson Medical School, Brunswick, NJ, USA, 3University of California San Francisco, School of Medicine, San Francisco, CA, USA, 4NYU School of Medicine, New York, NY, USA, 5Beth Israel Deaconess Medical Center, Boston, MA, USA, 6Boston Medical Center, Boston, MA, USA.
Objectives: The use of TEVARs to treat patients with both uncomplicated and complicated chronic Type B aortic dissections (tB-Ad) continues to rise, yet there exists limited national data evaluating outcomes and predictors of adverse events. We used prospectively collected data from the Vascular Quality Initiative (VQI) to evaluate (1) the presentation and clinical features of chronic aortic dissections, (2) the incidence of outcomes, and (3) predictors of these outcomes. Methods: We queried the VQI database (2011-2019) for patients undergoing TEVAR for chronic (>12 weeks) tB-Ad, dichotomizing patients into uncomplicated versus complicated (malperfusion, rupture, or rapid expansion) dissections. Outcomes included 30-day mortality, perioperative complications, and long-term survival (three years). Multivariable logistic regressions and Cox proportional hazard regressions accounted for confounding by adjusting for various factors. Results: We identified 535 patients treated for chronic Type B aortic dissection, with 80% presenting for aneurysmal degeneration, whereas 20% had complicated dissections which included malperfusion (75%), rupture (25%), and expansion (5%). Complicated and uncomplicated dissections had similar unadjusted rates of mortality (2.6% v .9%, p=.48) and complications (17% v. 13%, p=.26), and comparable three-year survival (95% v. 88%, p=.19). Complicated dissections were associated with longer procedural time (160min v. 130min, p<.01) and tended to have more visceral vessels incorporated (3.6 v 2.9, p<.02). Patients were more like to require one-year intervention in the case of complicated dissections (17% v 4.5%, p=.04). Multivariate analyses showed higher odds of 30-day mortality were associated with CAD (OR 1.1 [95%-CI 1.0- 1.1], P=.04), severe chronic kidney disease (OR 1.1 [1.0-1.2], P<.01), and emergent presentation (OR 1.2 [1.1-1.3], P<.01). Factors associated with decreased long-term survival included emergent repair (HR 6.6 [2.1-20], P<.01) and severe chronic kidney disease (HR 5.5 [1.9-16], P<.01). Conclusions: A significant portion of patients undergoing TEVAR for chronic tB-Ad presented for aneurysmal degeneration of chronic dissection. Most patients undergoing TEVAR for chronic dissections do very well; however, emergent clinical presentation is associated with worse procedural mortality and late survival. Further study is necessary to identify key risks for emergent presentation to improve outcomes further.
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