Grace J Wang1, Richard P Cambria2, Joseph V Lombardi3, Ali Azizzadeh4, Rodney A White5, Dorothy B Abel6, Jack L Cronenwett7, Adam W Beck8. 1. Division of Vascular Surgery and Endovascular Therapy, Hospital of the University of Pennsylvania, Philadelphia, Pa. 2. Division of Vascular Surgery, St. Elizabeth's Medical Center, Boston, Mass. 3. Division of Vascular and Endovascular Surgery, Cooper University Hospital, Camden, NJ. 4. Division of Vascular Surgery, Cedars-Sinai Medical Center, Los Angeles, Calif. 5. Vascular Surgery Services, Long Beach Memorial Heart & Vascular, Long Beach, Calif. 6. FDA Center for Devices and Radiological Health, Silver Spring, Md. 7. Division of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH. 8. Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala. Electronic address: awbeck@uabmc.edu.
Abstract
OBJECTIVE: The purpose of the Society for Vascular Surgery Vascular Quality Initiative thoracic endovascular aortic repair (TEVAR) for dissection project is to assess the effectiveness of TEVAR for type B dissection by evaluation in a prospective quality improvement registry. Here we describe the project cohort and 30-day outcomes of TEVAR for both acute dissection (AD) and chronic dissection (CD) patients and focus specifically on outcomes of uncomplicated AD patients based on timing of treatment. METHODS: Summary statistics were performed comparing patients with AD (<30 days) and patients with CD. Both groups were further divided into those with complicated (ie, malperfusion or rupture) or uncomplicated presentation. Further subdivision of the uncomplicated AD patients into treatment at ≤48 hours, >48 hours to <7 days, ≥7 days to ≤14 days, and >14 days to <30 days was performed. Kaplan-Meier analysis was performed for 30-day survival and freedom from reintervention. RESULTS: Data for 397 patients (204 AD patients and 193 CD patients) were collected from 40 institutions. Overall, AD patients were younger than CD patients (58.8 vs 62.2 years; P = .003). Technical success, including coverage of the primary entry tear, was 98.0% for AD patients and 99.0% for CD patients, with a trend toward a higher 30-day mortality in AD patients (AD, 9.3%; CD, 5.2%; P = .126). Any degree of procedure-related spinal cord ischemia occurred in 4.4% of AD patients vs 2.1% of CD patients (P = .261), with a deficit at discharge in 3.4% of AD patients vs 0.5% of CD patients (P = .068). Disabling stroke occurred in 2.5% of AD patients vs 1.6% of CD patients (P = .725); retrograde type A dissection occurred in 1.1% of AD patients vs 2.6% of CD patients (P = .412). There was a trend toward a lower freedom from reintervention in AD patients (90.7% vs 94.8%; P = .13). In uncomplicated AD patients, rapid aortic expansion was more common in the treatment groups of ≥7 days to ≤14 days and >14 days to <30 days compared with those treated within 7 days of dissection (P = .042). The uncomplicated AD cohorts based on timing of treatment were otherwise similar in demographics and presentation, with no significant differences in 30-day mortality or serious complications, such as spinal cord ischemia, stroke, or retrograde type A dissection. The 30-day reintervention rate for uncomplicated AD patients was 5.8%, with no apparent differences in reintervention rates according to timing of treatment of initial TEVAR. CONCLUSIONS: As expected, AD patients demonstrated a trend toward a higher 30-day mortality and lower freedom from reintervention compared with CD patients. Mortality at 30 days after TEVAR for uncomplicated AD was 5.8%, and there were no clear patterns in mortality or reintervention based on timing of treatment. Further study and evaluation at longer follow-up are needed to determine the impact of timing of intervention in uncomplicated AD patients.
OBJECTIVE: The purpose of the Society for Vascular Surgery Vascular Quality Initiative thoracic endovascular aortic repair (TEVAR) for dissection project is to assess the effectiveness of TEVAR for type B dissection by evaluation in a prospective quality improvement registry. Here we describe the project cohort and 30-day outcomes of TEVAR for both acute dissection (AD) and chronic dissection (CD) patients and focus specifically on outcomes of uncomplicated ADpatients based on timing of treatment. METHODS: Summary statistics were performed comparing patients with AD (<30 days) and patients with CD. Both groups were further divided into those with complicated (ie, malperfusion or rupture) or uncomplicated presentation. Further subdivision of the uncomplicated ADpatients into treatment at ≤48 hours, >48 hours to <7 days, ≥7 days to ≤14 days, and >14 days to <30 days was performed. Kaplan-Meier analysis was performed for 30-day survival and freedom from reintervention. RESULTS: Data for 397 patients (204 ADpatients and 193 CDpatients) were collected from 40 institutions. Overall, ADpatients were younger than CDpatients (58.8 vs 62.2 years; P = .003). Technical success, including coverage of the primary entry tear, was 98.0% for ADpatients and 99.0% for CDpatients, with a trend toward a higher 30-day mortality in ADpatients (AD, 9.3%; CD, 5.2%; P = .126). Any degree of procedure-related spinal cord ischemia occurred in 4.4% of ADpatients vs 2.1% of CDpatients (P = .261), with a deficit at discharge in 3.4% of ADpatients vs 0.5% of CDpatients (P = .068). Disabling stroke occurred in 2.5% of ADpatients vs 1.6% of CDpatients (P = .725); retrograde type A dissection occurred in 1.1% of ADpatients vs 2.6% of CDpatients (P = .412). There was a trend toward a lower freedom from reintervention in ADpatients (90.7% vs 94.8%; P = .13). In uncomplicated ADpatients, rapid aortic expansion was more common in the treatment groups of ≥7 days to ≤14 days and >14 days to <30 days compared with those treated within 7 days of dissection (P = .042). The uncomplicated AD cohorts based on timing of treatment were otherwise similar in demographics and presentation, with no significant differences in 30-day mortality or serious complications, such as spinal cord ischemia, stroke, or retrograde type A dissection. The 30-day reintervention rate for uncomplicated ADpatients was 5.8%, with no apparent differences in reintervention rates according to timing of treatment of initial TEVAR. CONCLUSIONS: As expected, ADpatients demonstrated a trend toward a higher 30-day mortality and lower freedom from reintervention compared with CDpatients. Mortality at 30 days after TEVAR for uncomplicated AD was 5.8%, and there were no clear patterns in mortality or reintervention based on timing of treatment. Further study and evaluation at longer follow-up are needed to determine the impact of timing of intervention in uncomplicated ADpatients.
Authors: Eric Y Pruitt; Salvatore T Scali; Dean J Arnaoutakis; Martin R Back; George J Arnaoutakis; Tomas D Martin; Thomas M Beaver; Thomas S Huber; Gilbert R Upchurch Journal: J Cardiovasc Surg (Torino) Date: 2020-09-23 Impact factor: 1.888
Authors: Michael L Williams; Madeleine de Boer; Bridget Hwang; Bruce Wilson; John Brookes; Nicholas McNamara; David H Tian; Timothy Shiraev; Ourania Preventza Journal: Ann Cardiothorac Surg Date: 2022-01
Authors: Jack L Cronenwett; Erika Avila-Tang; Adam W Beck; Daniel Bertges; Jens Eldrup-Jorgensen; Frederic S Resnic; Nadezda Radoja; Art Sedrakyan; Andreas Schick; Josh Smale; Roberta A Bloss; Peter Phillips; Melissa Hasenbank; Shengchun Wang; Danica Marinac-Dabic; Gregory Pappas Journal: BMJ Surg Interv Health Technol Date: 2020-10-30