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Distal Extent Of Dissection Increases Risk Of Malperfusion Syndromes And Need For Reoperation In Patients With Acute Type B Aortic Dissection
Michelle N. Manesh, MD
1, Helen A. Potter, MD
2, Alexander D. Dibartolomeo, MD
1, Li Ding, MD, PhD
1, Sukgu M. Han, MD, MS
1, Alyssa Pyun, MD
1, Niema Pahlevan, PhD
1, Gregory A. Magee, MD
1.
1University Of Southern California, Los Angeles, CA, USA,
2University of Buffalo, Buffalo, NY, USA.
Objectives: There is limited data on the impact of distal extent of dissection (DoD) in patients with acute type B aortic dissection (aTBAD). We aimed to evaluate the impact of DoD on malperfusion syndromes, reintervention, and mortality in patients undergoing TEVAR for aTBAD.
Methods: The SVS VQI registry was queried from 2012-2022 for patients undergoing TEVAR for aTBAD. Primary exposure variable was DoD, categorized as thoracic (zones 2-5), abdominal (zones 6-9) or iliac (zones 10-11). Primary outcomes were malperfusion on presentation (renal, mesenteric, lower extremity [LE]) and mortality after TEVAR. Secondary outcomes were reoperation and resolution of malperfusion after TEVAR. Three-way logistic regression models were created to evaluate resolution of malperfusion after TEVAR based on DoD (DoD was inlcluded as the independent variable by which the rates of preoperative and postoperative malperfusion were compared in each patient). Multivariable logistic regression was performed for 30-day and 2-year mortality.
Results: Of 2,455 included patients, DoD was relatively evenly distributed between thoracic (32%), abdominal (26%), and iliac (42%) regions. A more DoD was associated with a stepwise increase in intestinal (5% vs. 14% vs. 20%, p<.0001), renal (7% vs. 18% vs. 27%, p<.0001), and LE malperfusion (6% vs. 9% vs. 27%, p<.0001) on presentation. DoD was associated with reoperation (11% vs. 15% vs. 17%, p=.0017), and residual intestinal (2% vs. 5% vs. 6%, p=0009) and renal (3% vs. 5.5% vs. 6%, p=0.0036) malperfusion after TEVAR. DoD was also associated with higher rates of resolution of renal, intestinal and LE malperfusion after TEVAR (p<.0001 for all). On multivariable analysis, DoD was not associated with mortality (p>0.05 for all).
Conclusions: DoD is not independently associated with mortality, but is associated with need for reoperation and residual intestinal and renal malperfusion after TEVAR. However, DoD is also associated with increased likelihood of resolution of malperfusion after TEVAR. These finding suggest that flow dynamics in aTBAD are dependent on DoD and may fluctuate soon after TEVAR.
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| Table 1. Outcomes associated with distal extent of dissection in patients with aTBAD undergoing TEVAR |
|
| Total (n=2455) | Thoracic (n=779) | Abdominal (n=634) | Iliac (n=1042) | p-value |
| Preoperative Malperfusion | | | | | |
| Intestinal ischemia | 332 (13.5%) | 40 (5.1%) | 86 (13.6%) | 206 (19.8%) | <0.0001 |
| Renal ischemia | 448 (18.3%) | 52 (6.7%) | 112 (17.7%) | 284 (27.3%) | <0.0001 |
| Leg ischemia | 385 (15.7%) | 45 (5.8%) | 55 (8.7%) | 285 (27.4%) | <0.0001 |
| | | | | |
| Postoperative malperfusion | | | | | |
| Intestinal ischemia | 112 (4.6%) | 19 (2.4%) | 29 (4.6%) | 64 (6.1%) | 0.0009 |
| Renal ischemia | 118 (4.8%) | 21 (2.7%) | 35 (5.5%) | 62 (6.0%) | 0.0036 |
| Leg ischemia | 58 (2.4%) | 13 (1.7%) | 13 (2.1%) | 32 (3.1%) | 0.1253 |
| | | | | |
| Re-operation | 361 (14.8%) | 87 (11.3%) | 95 (15.0%) | 179 (17.3%) | 0.0017 |
| For Aorta/branch | 153 (6.5%) | 41 (5.5%) | 45 (7.4%) | 67 (6.8%) | 0.3513 |
| For Rupture | 4 (0.2%) | 1 (0.1%) | 1 (0.2%) | 2 (0.2%) | 0.99 |
| For Aortic enlargement | 5 (0.2%) | 2 (0.3%) | 2 (0.3%) | 1 (0.1%) | 0.62 |
| For False lumen patency | 12 (0.5%) | 4 (0.6%) | 3 (0.5%) | 5 (0.5%) | 0.99 |
| For Extension of dissection | 19 (0.9%) | 5 (0.7%) | 6 (1.0%) | 8 (0.9%) | 0.7964 |
| For Malperfusion | 51 (2.3%) | 6 (0.8%) | 16 (2.7%) | 29 (3.1%) | 0.0052 |
| For Device factors | 9 (0.4%) | 0 (0.0%) | 5 (0.9%) | 4 (0.4%) | 0.03 |
| For Bleeding | 5 (0.2%) | 3 (0.4%) | 1 (0.2%) | 1 (0.1%) | 0.46 |
| For Other reason | 33 (1.5%) | 12 (1.7%) | 8 (1.4%) | 13 (1.4%) | 0.8942 |
| | | | | |
| 30-day mortality | 193 (7.9%) | 51 (6.5%) | 58 (9.1%) | 84 (8.1%) | 0.1859 |
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