Endovascular repair of type B aortic dissection: long-term results of the randomized investigation of stent grafts in aortic dissection trial.

Abstract

BACKGROUND:

Thoracic endovascular aortic repair (TEVAR) represents a therapeutic concept for type B aortic dissection. Long-term outcomes and morphology after TEVAR for uncomplicated dissection are unknown.

METHODS AND RESULTS:

A total of 140 patients with stable type B aortic dissection previously randomized to optimal medical treatment and TEVAR (n=72) versus optimal medical treatment alone (n=68) were analyzed retrospectively for aorta-specific, all-cause outcomes, and disease progression using landmark statistical analysis of years 2 to 5 after index procedure. Cox regression was used to compare outcomes between groups; all analyses are based on intention to treat. The risk of all-cause mortality (11.1% versus 19.3%; P=0.13), aorta-specific mortality (6.9% versus 19.3%; P=0.04), and progression (27.0% versus 46.1%; P=0.04) after 5 years was lower with TEVAR than with optimal medical treatment alone. Landmark analysis suggested a benefit of TEVAR for all end points between 2 and 5 years; for example, for all-cause mortality (0% versus 16.9%; P=0.0003), aorta-specific mortality (0% versus 16.9%; P=0.0005), and for progression (4.1% versus 28.1%; P=0.004); Landmarking at 1 year and 1 month revealed consistent findings. Both improved survival and less progression of disease at 5 years after elective TEVAR were associated with stent graft induced false lumen thrombosis in 90.6% of cases (P<0.0001).

CONCLUSIONS:

In this study of survivors of type B aortic dissection, TEVAR in addition to optimal medical treatment is associated with improved 5-year aorta-specific survival and delayed disease progression. In stable type B dissection with suitable anatomy, preemptive TEVAR should be considered to improve late outcome.

CLINICAL TRIAL REGISTRATION URL:

http://www.clinicaltrials.gov. Unique identifier: NCT01415804.

• Authors: Christoph A Nienaber, Stephan Kische, Hervé Rousseau, Holger Eggebrecht, Tim C Rehders, Guenther Kundt, Aenne Glass, Dierk Scheinert, Martin Czerny, Tilo Kleinfeldt, Burkhart Zipfel, Louis Labrousse, Rossella Fattori, Hüseyin Ince, INSTEAD-XL trial
• Journal: Circulation. Cardiovascular interventions (Circ Cardiovasc Interv) Vol. 6 Issue 4 Pg. 407-16 (Aug 2013) ISSN: 1941-7632 [Electronic] United States
• PMID: 23922146 (Publication Type: Journal Article, Randomized Controlled Trial, Research Support, Non-U.S. Gov't)

Topics

• Adult
• Aged
• Aortic Dissection (mortality, pathology, surgery)
• Aorta, Thoracic (pathology)
• Aortic Aneurysm, Thoracic (mortality, pathology, surgery)
• Blood Vessel Prosthesis Implantation (methods)
• Disease Progression
• Female
• Humans
• Male
• Middle Aged
• Proportional Hazards Models
• Stents