Progress in management of malperfusion syndrome from type B dissections

Colin Ryan, Lina Vargas, Tara Mastracci, Sunita Srivastava, Mathew Eagleton, Rebecca Kelso, Daniel Clair, Timur P Sarac
Journal of Vascular Surgery 2013, 57 (5): 1283-90; discussion 1290

OBJECTIVE: Malperfusion syndrome is a known predictor of poor outcomes in acute type B dissection. We describe our experience with revascularization in the acute setting.

METHODS: Patients undergoing intervention for ischemia complicated acute type B dissection between November 1999 and March 2011 were reviewed. Details of presenting condition, surgical intervention, and postoperative course were collected. Descriptive and inferential statistical analyses included survival and freedom from reintervention using Cox proportional hazards models.

RESULTS: A total of 61 patients were identified with malperfusion in at least one territory, including spinal cord 7/61 (12%), mesenteric 37/61 (61%), renal 45/61 (73%), and lower extremity 38/61 (62%). Thoracic stent grafts were placed in all patients, and 41% of patients required adjunctive branch vessel stenting. After intervention, resolution of the ischemia was reported in 57/61 (93%) of patients. The 30-day/in-hospital mortality was 21.3%. The 6-month, 1-year, and 5-year survival was 75% (95% CI, 65%-87%), 71% (95% CI, 61%-84%), and 56% (95% CI, 43%-74%), respectively. The 6-month, 1-year, and 5-year freedom from reintervention was 84% (95% CI, 75%-95%), 76% (95% CI, 65%-90%), and 42% (95% CI, 24%-76%), respectively. Territory of ischemia was not independently associated with mortality, but placement of a stent graft proximal to the subclavian artery was associated with poor outcome hazard ratio 2.91 (95% CI, 1.09-8.11; P = .034).

CONCLUSIONS: Malperfusion in any territory at the time of presentation in patients with type B dissections can be treated with endovascular intervention with acceptable outcomes. Opposed to branch vessel intervention alone, increased aortic intervention with regard to proximal coverage may signify more serious disease is associated with worse outcome.

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