James C Iannuzzi1, Sahael M Stapleton2, Yanik J Bababekov2, David Chang2, Robert T Lancaster1, Mark F Conrad1, Richard P Cambria1, Virendra I Patel3. 1. Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass. 2. Codman Center, Department of Surgery, Massachusetts General Hospital, Boston, Mass. 3. Division of Vascular Surgery and Endovascular Interventions, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY. Electronic address: vp2385@cumc.columbia.edu.
Abstract
BACKGROUND: In uncomplicated type B aortic dissection (UTBAD), the "gold standard" has been nonoperative treatment with medical therapy, although this has been questioned by studies demonstrating improved outcomes in those treated with thoracic endovascular aortic repair (TEVAR). This study assessed long-term survival after acute UTBAD comparing medical therapy, open repair, and TEVAR. METHODS: The California Office of Statewide Hospital Planning Development database was analyzed from 2000 to 2010 for adult patients with acute UTBAD. Patients with nonemergent admission for aortic dissection, type A dissection, trauma, bowel ischemia, lower extremity ischemia, acidosis, or shock were excluded. The cohort was stratified by treatment type at index admission into medical therapy, open surgical repair, and TEVAR. Multivariable regression and survival analyses were used to evaluate the association of treatment type with long-term overall survival. RESULTS: There were 9165 cases, 95% medical therapy, 2% open repair, and 2.9% TEVAR. The mean age was 66 ± 15 years, with 39% female, 2.4% cocaine users, 18% with congestive heart failure, and 17% with Charlson Comorbidity Index >3. Mean inpatient costs were $57,000 for medical therapy, $200,000 for open repair, and $130,000 for TEVAR (P < .01). Inpatient mortality was 6.5% overall, 6.3% for medical therapy, 14% for open repair, and 7.1% for TEVAR (P < .01). One-year and 5-year survivals were 84% and 60% in medical therapy, 76% and 67% in open repair, and 85% and 76% in TEVAR (log-rank, P < .01). On risk-adjusted multivariable analysis, TEVAR had improved survival compared with medical therapy (hazard ratio, 0.68; 95% confidence interval, 0.6-0.8; P < .01), with no difference between open repair and medical therapy (hazard ratio, 1.0; 95% confidence interval, 0.8-1.3; P < .01). CONCLUSIONS: This statewide study on survival after acute UTBADs shows an independent survival advantage for TEVAR over medical therapy. These data add further evidence for a paradigm shift in acute management of type B dissection in favor of early TEVAR.
BACKGROUND: In uncomplicated type B aortic dissection (UTBAD), the "gold standard" has been nonoperative treatment with medical therapy, although this has been questioned by studies demonstrating improved outcomes in those treated with thoracic endovascular aortic repair (TEVAR). This study assessed long-term survival after acute UTBAD comparing medical therapy, open repair, and TEVAR. METHODS: The California Office of Statewide Hospital Planning Development database was analyzed from 2000 to 2010 for adult patients with acute UTBAD. Patients with nonemergent admission for aortic dissection, type A dissection, trauma, bowel ischemia, lower extremity ischemia, acidosis, or shock were excluded. The cohort was stratified by treatment type at index admission into medical therapy, open surgical repair, and TEVAR. Multivariable regression and survival analyses were used to evaluate the association of treatment type with long-term overall survival. RESULTS: There were 9165 cases, 95% medical therapy, 2% open repair, and 2.9% TEVAR. The mean age was 66 ± 15 years, with 39% female, 2.4% cocaine users, 18% with congestive heart failure, and 17% with Charlson Comorbidity Index >3. Mean inpatient costs were $57,000 for medical therapy, $200,000 for open repair, and $130,000 for TEVAR (P < .01). Inpatient mortality was 6.5% overall, 6.3% for medical therapy, 14% for open repair, and 7.1% for TEVAR (P < .01). One-year and 5-year survivals were 84% and 60% in medical therapy, 76% and 67% in open repair, and 85% and 76% in TEVAR (log-rank, P < .01). On risk-adjusted multivariable analysis, TEVAR had improved survival compared with medical therapy (hazard ratio, 0.68; 95% confidence interval, 0.6-0.8; P < .01), with no difference between open repair and medical therapy (hazard ratio, 1.0; 95% confidence interval, 0.8-1.3; P < .01). CONCLUSIONS: This statewide study on survival after acute UTBADs shows an independent survival advantage for TEVAR over medical therapy. These data add further evidence for a paradigm shift in acute management of type B dissection in favor of early TEVAR.
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