Early open and endovascular thoracic aortic repair for complicated type B aortic dissection

Background: Aortic repair for acute (<2 weeks) or subacute (2 to 8 weeks) type B dissection is performed for rupture, impending rupture, or malperfusion. Thoracic aortic endovascular repair (TEVAR) has been suggested as a more suitable, less invasive alternative to open descending aortic repair for type B dissection, but a comparative analysis is warranted. Methods: Seventy-three patients with type B dissection (1995 to 2012) underwent early open descending aortic repair (n = 24) or TEVAR (n = 49). Mean age was 66.3 years. Intervention occurred in the acute (n = 53) or subacute (n = 20) period for malperfusion (n = 8), rupture (n = 22), or factors portending rupture, including rapid expansion (n = 26), uncontrolled pain (n = 18), aortic size greater than 5.0 cm (n = 26), or refractory hypertension (n = 2). Twenty-six had multiple indications. Patients undergoing TEVAR were older and had an increased incidence of coronary artery disease and renal impairment (all p < 0.05). Results: Thirty-day mortality was 12% (n = 9). Morbidity included stroke (n = 7), dialysis (n = 6), paralysis (n = 4), and tracheostomy (n = 7). A composite outcome of mortality and these morbidities independently correlated with presentation with frank rupture (p < 0.01) or limb ischemia (p = 0.03), but not treatment strategy (p = 0.3). Ten-year Kaplan-Meier survival was 57.5% and similar between groups (p = 0.74). Independent predictors of late mortality included perioperative stroke and presentation with rupture during late follow-up (both p < 0.02). Five-year freedom from aortic reintervention or rupture was similar between TEVAR (80.0%) and open descending aortic repair (82.8%; p = 0.45). Conclusions: Early aortic repair for complicated type B dissection is associated with high rates of morbidity, late mortality, and reintervention. Despite its use in a higher risk group, outcomes seen with TEVAR were similar to open repair, thus supporting the recent paradigm shift toward an endovascular approach.