Early Thoracic Endovascular Aortic Repair for Acute Type B Dissection Is Associated with Increased Complications: Results from the Gore Global Registry for Endovascular Aortic Treatment Registry.

BACKGROUND: Several recent small trials have suggested that there is a potential benefit of early thoracic endovascular aortic repair (TEVAR) for acute type B aortic dissection (TBAD), even for uncomplicated patients. We studied patients enrolled in the Gore Global Registry for Endovascular Aortic Treatment (GREAT) to compare outcomes of TEVAR in the early-acute phase with and without complicated presentation.

METHODS: The GREAT registry was queried for patients treated with TEVAR for TBAD. Acute phase of TBAD was defined as hospitalization within 14 days of symptom onset. Time to treatment was computed as time from first symptoms to time of TEVAR implantation regardless of the preoperative duration of hospitalization. Complicated presentation of acute TBAD was designated by the treating clinical sites, and treatment strategy was determined at the physician's discretion, as was common practice at the time of registry conception in 2010; therefore, the designation of "complicated" presentation in this study differs from the most recent Society for Vascular Surgery/Society of Thoracic Surgeons reporting standards, which refers exclusively to malperfusion and rupture. All patients received TEVAR with Gore TAG or CTAG devices (W.L. Gore & Associates, Flagstaff, Arizona). The primary exposure variable was time from symptom onset to TEVAR, stratified by complicated versus uncomplicated presentation. The primary outcome was postoperative aortic complications, defined as endoleak, extended or new dissection (including retrograde type A dissection), rupture, enlargement or aneurysmal degeneration, requirement for reinterventions, conversion to open repair, and graft infection. Univariate data were analyzed by contingency table and unpaired t-test or Wilcoxon rank sum, and adjusted analyses were conducted using stratified and multiple logistic and Cox regression techniques. Data were analyzed by an independent academic research team.

RESULTS: Of the 5,014 patients enrolled in the GREAT registry between 2011 and 2016, there were 172 patients who received TEVAR for TBAD; 40 of 172 (23%) were female and the mean age was 61 ± 12 years. There were 102 (59%) with complicated presentations. After adjustment for complicated presentation, TEVAR performed within 3 days of symptom onset was independently associated with increased rate of short-term (odds ratio, 2.4, P < 0.039), and intermediate-term (hazard ratio 2.31, P < 0.024) aortic complications. TEVAR performed within 3 days was also associated with increased rates of aortic reinterventions, branch vessel complications, renal complications, and aortic complication/death at 6 months when compared with delayed repair.

CONCLUSION: These data suggest that TEVAR performed at least 3 days after acute TBAD is associated with less morbidity and mortality. When possible, TEVAR should be delayed by at least 3 days for patients with uncomplicated acute TBAD to offer maximum risk reduction.