Complicated acute type B dissection: is surgery still the best option?: a report from the International Registry of Acute Aortic Dissection

Rossella Fattori, Thomas T Tsai, Truls Myrmel, Arturo Evangelista, Jeanna V Cooper, Santi Trimarchi, Jin Li, Luigi Lovato, Stephan Kische, Kim A Eagle, Eric M Isselbacher, Christoph A Nienaber
JACC. Cardiovascular Interventions 2008, 1 (4): 395-402

OBJECTIVES: Impact on survival of different treatment strategies was analyzed in 571 patients with acute type B aortic dissection enrolled from 1996 to 2005 in the International Registry of Acute Aortic Dissection.

BACKGROUND: The optimal treatment for acute type B dissection is still a matter of debate.

METHODS: Information on 290 clinical variables were compared, including demographics; medical history; clinical presentation; physical findings; imaging studies; details of medical, surgical, and endovascular management; in-hospital clinical events; and in-hospital mortality.

RESULTS: Of the 571 patients with acute type B aortic dissection, 390 (68.3%) were treated medically, 59 (10.3%) with standard open surgery and 66 (11.6%) with an endovascular approach. Patients who underwent emergency endovascular or open surgery were younger (mean age 58.8 years, p < 0.001) than their counterparts treated conservatively, and had male preponderance and hypertension in 76.9%. Patients submitted to surgery presented with a wider aortic diameter than patients treated by interventional techniques or by medical therapy (5.36 +/- 1.7 cm vs. 4.62 +/- 1.4 cm vs. 4.47 +/- 1.4 cm, p = 0.003). In-hospital complications occurred in 20% of patients subjected to endovascular technique and in 40% of patients after open surgical repair. In-hospital mortality was significantly higher after open surgery (33.9%) than after endovascular treatment (10.6%, p = 0.002). After propensity and multivariable adjustment, open surgical repair was associated with an independent increased risk of in-hospital mortality (odds ratio: 3.41, 95% confidence interval: 1.00 to 11.67, p = 0.05).

CONCLUSIONS: In the International Registry of Acute Aortic Dissection, the less invasive nature of endovascular treatment seems to provide better in-hospital survival in patients with acute type B dissection; larger randomized trials or comprehensive registries are needed to access impact on outcomes.

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