Complicated Versus High-risk Patients Undergoing Thoracic Endovascular Aortic Repair For Acute Type B Aortic Dissection
Amanda Filiberto, MD, Christopher Jacobs, M.D., Brian Fazzone, MD, Erik Anderson, MD, Jonathan Krebs, MD, Gilbert Upchurch, MD, Michol Cooper, MD.
University of Florida, Gainesville, FL, USA.
Background: Recently the SVS and STS published contemporary guidelines clearly defining complicated vs uncomplicated type B aortic dissections (TBADs) with an additional high-risk grouping. Few studies have evaluated outcomes associated with “high risk” vs “complicated” TBADs. The objective of this study was to assess differences in demographics, clinical presentation, symptom onset, and outcomes in patients undergoing thoracic endovascular aortic repair (TEVAR) for acute complicated and high-risk TBADs. Methods: Patients undergoing TEVAR (n=101) for acute complicated and high-risk TBADs from a single academic medical center were analyzed. Per STS/SVS 2020 guidelines, high-risk was defined as refractory pain/hypertension and complicated was defined as ruptured/malperfusion presentation. The primary end-point was inpatient mortality. Secondary end-points included complications, re-intervention and survival. Logistic regression was used for risk-adjusted comparisons and life-table methodology estimated freedom from end-points. Results: 63 patients (63%) were classified as complicated (C-TBAD) and 38 patients (38%) were classified as high risk (HR-TBAD). There were no differences in age, sex or time from onset of symptoms. C-TBAD had significantly increased ASA, risk of any complication (70 vs 50%,p=.046) and mean complications (1.2 vs 0.63, p=.003) yet similar re-intervention rates. Importantly, there were no inpatient or 60-day deaths in HR-TBADs while there was a significant increase in C-TBADs at 21% (p=.002) and 25%(p=.004), respectively. C-TBADs had poorer long-term survival at 70, 65 and 61% at 1,3 and 5-years vs 100, 93 and 88%,p=.002(Figure 1). On multivariate regression, the strongest independent predictor of mortality was cardiovascular disease(HR 5.6,CI 2.3-14,p<.001) followed by C-TBAD status (HR 5.1,CI 1.5-18,p.01). Conclusions: Consistent with the newly updated STS/SVS guidelines, patients with acute complicated TBADs undergoing TEVAR have poorer perioperative and long-term outcomes compared with those TBADs with high-risk features. These findings may improve preoperative surgical risk stratification and patient counselling. 
Table I. Patient characteristics
| Demographics | Complicated (n=63) | High-risk (n=38) | p-value |
| Age, mean (SD) | 57.7 (12.4) | 59.1 (13.0) | .590 |
| Female Sex, n (%) | 13 (20.6) | 10 (26.3) | .625 |
| Preop BMI | 24±7 | 22±5 | .09 |
| ASA Class | .018 | ||
| 3E | 9 (14.5) | 9 (23.7) | |
| 4E | 42 (67.7) | 29 (76.3) | |
| 5E | 11 (17.7) | 0 (0) | |
| Time from onset symptoms (median, [IQR]) | 5 (2, 24) | 5 (2, 36) | .914 |
| Outcomes | |||
| LOS, days (median, [IQR]) | 12 (9, 22) | 11.5 (7, 15) | .08 |
| Any complication | 44 (70) | 19 (50) | .046 |
| Mean complications | 1.2±1.1 | 0.63±0.81 | .003 |
| Cardiac complications | 7 (11.1) | 2 (5.3) | .48 |
| Renal complications | 13 (20.6) | 2 (5.3) | .044 |
| Gastrointestinal | 6 (9.5) | 2 (5.3) | .71 |
| Neuro | 9 (14.3) | 5 (13.2) | 1 |
| Pulmonary | 15 (23.8) | 4 (10.5) | .12 |
| Reintervention, n (%) | 11 (17.5) | 11 (29.0) | .22 |
| Mortality, n (%) | |||
| Inpatient | 13 (21.0) | 0 (0) | .002 |
| 60-day | 16 (25.4) | 0 (0) | .004 |
ASA, American Society of Anesthesiology classification; CAD, coronary artery disease; COPD, chronic obstructive pulmonary disease; CHF, congestive heart failure
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