Contemporary outcomes of open repair of acute complicated type B aortic dissection

Christopher Lau; Giovanni Jr Soletti; Kendall M Lawrence; Mohamed Rahouma; Erin Iannacone; Ivancarmine Gambardella; Mario Gaudino; Leonard N Girardi

doi:10.1016/j.jvs.2023.04.042

Contemporary outcomes of open repair of acute complicated type B aortic dissection

J Vasc Surg. 2023 Sep;78(3):593-601.e4. doi: 10.1016/j.jvs.2023.04.042. Epub 2023 May 19.

Authors

Christopher Lau¹, Giovanni Jr Soletti², Kendall M Lawrence³, Mohamed Rahouma², Erin Iannacone², Ivancarmine Gambardella², Mario Gaudino², Leonard N Girardi²

Affiliations

¹ Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY. Electronic address: chl9077@med.cornell.edu.
² Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY.
³ Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA.

PMID: 37211141
DOI: 10.1016/j.jvs.2023.04.042

Abstract

Objective: Open repair of acute complicated type B aortic dissection (ACTBAD), required when endovascular repair is not possible, is historically considered high-risk. We analyze our experience with this high-risk cohort compared with the standard cohort.

Methods: We identified consecutive patients undergoing descending thoracic or thoracoabdominal aortic aneurysm (TAAA) repair from 1997 to 2021. Patients with ACTBAD were compared with those having surgery for other reasons. Logistic regression was used to identify associations with major adverse events (MAEs). Five-year survival and competing risk of reintervention were calculated.

Results: Of 926 patients, 75 (8.1%) had ACTBAD. Indications included rupture (25/75), malperfusion (11/75), rapid expansion (26/75), recurrent pain (12/75), large aneurysm (5/75), and uncontrolled hypertension (1/75). The incidence of MAEs was similar (13.3% [10/75] vs 13.7% [117/851], P = .99). Operative mortality was 5.3% (4/75) vs 4.8% (41/851) (P = .99). Complications included tracheostomy (8%, 6/75), spinal cord ischemia (4%, 3/75), and new dialysis (2.7%, 2/75). Renal impairment, urgent/emergent operation, forced expiratory volume in 1 second ≤50%, and malperfusion were associated with MAEs, but not ACTBAD (odds ratio: 0.48, 95% confidence interval [CI]: [0.20-1.16], P = .1). At 5 and 10 years, there was no difference in survival (65.8% [95% CI: 54.6-79.2] vs 71.3% [95% CI: 67.9-74.9], P = .42, and 47.3% [95% CI: 34.5-64.7] vs 53.7% [95% CI: 49.3-58.4], P = .29, respectively) or 10-year reintervention (12.5% [95% CI: 4.3-25.3] vs 7.1% [95% CI: 4.7-10.1], P = .17, respectively).

Conclusions: In an experienced center, open repair of ACTBAD can be performed with low rates of operative mortality and morbidity. Outcomes similar to elective repair are achievable even in high-risk patients with ACTBAD. In patients unsuitable for endovascular repair, transfer to a high-volume center experienced in open repair should be considered.

Keywords: Aortic dissection; Aortic operation; Outcomes; Type B dissection.

MeSH terms

Aneurysm* / surgery
Aortic Aneurysm, Thoracic* / complications
Aortic Aneurysm, Thoracic* / diagnostic imaging
Aortic Aneurysm, Thoracic* / surgery
Aortic Dissection* / diagnostic imaging
Aortic Dissection* / surgery
Blood Vessel Prosthesis Implantation* / adverse effects
Endovascular Procedures* / adverse effects
Humans
Postoperative Complications
Retrospective Studies
Risk Assessment
Risk Factors
Treatment Outcome