Risk Factors Predicting Perioperative And Long-Term Mortality In Acute & Subacute TEVAR Patients
Abhishek Devaguptapu Rao, BA/BS1, Ambar Mehta, MD, MPH1, Richard Schutzer, MD1, Danielle Bajakian, MD1, Nicholas Morrissey, MD1, Eric Trestman, MD1, Karan Garg, MD2, Marc Schermerhorn, MD3, Hiroo Takayama, MD1, Virendra Patel, MD1.
1Columbia University, New York, NY, USA, 2NYU School of Medicine, New York, NY, USA, 3Beth Israel Deaconess Medical Center, New Boston, MA, USA.
Objectives: The use of TEVARs to treat patients with both uncomplicated and complicated acute 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 acute 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 acute (<2 weeks) and sub-acute (2-12 weeks) tB-Ad, dichotomizing patients into uncomplicated versus complicated (malperfusion, rupture, increased size, or expansion) dissections. Outcomes included 30-day mortality, perioperative complications, and long-term survival (three-year). Risk adjusted analyses were performed using multivariable and Cox proportional hazard regression. Results: We identified 1078 patients treated for tB-Ad, with 44.1% having complicated dissections including malperfusion (66%), rupture (20%), and expansion (16%). Overall 30-day mortality and complication rates were 9.6% and 32%. Complicated dissections had higher unadjusted rates of 30-day mortality (15% v. 5.3%, p<.01), and complications (44% v. 22%, p<.01), and lower three-year survival (75% v. 81%, p<.01). Post- operative spinal ischemia was more common in complicated dissections (11% v. 3.3 %; p<.01), as was stroke (8.2% v. 3.7%; p<.01) and acute kidney injury (5.9% v. 1.0%; p<.01). Complicated dissections required more visceral vessel incorporation (82% v. 67%, p<.01), arm or neck access (20% v. 15%, p=.02), and higher 30-day reintervention (19% v. 8.4%, p<.01). Multivariate analyses showed complicated dissections had higher odds of 30-day mortality (OR 1.0 [95%- CI 1.0-1.1], P=.01) and perioperative complications (OR 1.1 [1.1-1.2], P<.01). Factors associated with decreased long-term survival included emergent repair (HR 2.3 [1.5-3.6], P<.01), severe CKD (OR 2.2 [1.3-3.9], P<.01), and CAD (HR 2.0 [1.4- 2.9], P<.01). Conclusions: These data present contemporary results of TEVAR for tB-Ad, showing excellent mortality and morbidity for both uncomplicated and complicated presentations compared to prior reports of medical and surgical therapy. In light of these findings, early aggressive intervention with TEVAR remains a necessity for complicated presentation and should be strongly considered in patients with acute uncomplicated tB-Ad.
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