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Five-year outcomes of endovascular repair of complicated acute type B aortic dissections

      Abstract

      Objective

      Thoracic endovascular aortic repair is the standard of care for acute complicated type B aortic dissections, but long-term single-device outcomes are limited.

      Methods

      Fifty patients were treated with the Valiant Captivia thoracic stent graft (Medtronic Inc, Santa Rosa, Calif) for acute complicated type B aortic dissections in this prospective, nonrandomized Dissection Trial. All-cause mortality, secondary procedures, and serious adverse events were assessed, and a core lab evaluated images for aortic remodeling.

      Results

      Compliance for both clinical and imaging follow-up was 78% (18 out of 23) for the available patients at 5 years. Notable baseline characteristics were 86% of patients (43 out of 50) had malperfusion, 20% (10 out of 50) had ruptures, and 94% (46 out of 49) had DeBakey class IIIB dissections. The 5-year freedom from dissection-related mortality, secondary procedures related to the dissection, and endoleaks was 83%, 86%, and 85%, respectively. After 5 years, 89% of patients (16 out of 18) had a completely thrombosed false lumen in the stented segment of the aorta and the true lumen diameter over the length of stent graft was stable or increased for 94% of patients (16 out of 17) while the false lumen diameter was stable or decreased in 77% (13 out of 17) after 5 years.

      Conclusions

      In the Dissection Trial, patients experienced positive and sustained measures of aortic remodeling. Survival outcomes, need for secondary procedures, and adverse event rates were consistent with previous thoracic endovascular aortic repair studies. Although limitations exist with the follow-up compliance, the Valiant Captivia thoracic stent graft system was effective in the long-term management of acute complicated type B aortic dissections in this patient population with a challenging condition.

      Graphical abstract

      Key Words

      Abbreviations and Acronyms:

      ACM (all-cause mortality), INSTEAD-XL (Investigation of Stent Grafts in Aortic Dissection with extended length of follow-up), IRAD (International Registry of Acute Aortic Dissection), LSA (left subclavian artery), PVD (peripheral vascular disease), RTAD (retrograde type A dissection), TBAD (type B aortic dissection), TEVAR (thoracic endovascular aortic repair)
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      Linked Article

      • Commentary: Are the early benefits of thoracic endovascular aortic repair in complicated type B dissection durable through time?
        The Journal of Thoracic and Cardiovascular SurgeryVol. 163Issue 2
        • Preview
          The introduction of thoracic endovascular aortic repair (TEVAR) procedures have revolutionized the treatment of complicated type B aortic dissection. Perioperative mortality rates have declined from 30% to 50% for a classic open repair to 10% in the TEVAR era.1 Although the benefits of TEVAR to decrease early morbidity and mortality are indisputable, data on late outcomes remain limited. Bavaria and colleagues2 report good clinical outcomes at 5 years in a multicenter nonrandomized trial of 50 patients with acute type B aortic dissection with malperfusion treated with the Valiant Captivia device (Medtronic, Minneapolis, Minn).
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      • Commentary: It’s not how you drive—it’s how you arrive!
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          Although acute type A aortic dissection is a life-threatening event, dissection affecting the distal aorta—type B aortic dissection—is far less lethal in most circumstances. The traditional treatment paradigm for acute type B aortic dissection (ATBAD) stresses medical management for the vast majority of patients, who are without serious complication. However, for the few patients with ATBAD and complications (eg, malperfusion, rupture, rapid aortic expansion, severe pain, and other factors), action must be taken to avoid catastrophe.
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        • PDF