Adjunctive branch interventions during thoracic endovascular aortic repair for acute complicated type B dissection are not associated with inferior outcomes

Abstract

Objective: Thoracic endovascular aortic repair (TEVAR) has been shown to effectively treat malperfusion associated with acute type B thoracic aortic dissection (TBAD). A subset of patients might still require adjunctive peripheral or visceral artery branch interventions during TEVAR to remedy persistent end organ malperfusion. Our objectives were to determine the incidence of these adjunctive interventions and to compare the outcomes between patients who had and had not undergone such interventions.

Methods: We performed a retrospective review of the TEVAR and complex EVAR module of the Vascular Quality Initiative from 2010 to 2019 to identify all patients treated for malperfusion due to acute TBAD. The anatomic branch and procedure performed at TEVAR were recorded. The 30-day mortality, need for reintervention, complication rates, and overall survival were compared between these patients stratified by adjunctive intervention status.

Results: A total of 426 patients had undergone TEVAR for acute TBAD with end organ malperfusion. Of the 426 patients, 126 (29.6%) had undergone 182 adjunctive branch interventions during TEVAR. The most common interventions were stenting (n = 86; 47.3%) and stent grafting (n = 49; 26.9%), with the most common site being the left renal artery (n = 49; 26.9%). The patients in both groups had similar 30-day mortality (12.4% with branch intervention vs 15.6% without; P = .511) and rates of in-hospital reintervention (19.2% with branch intervention vs 20.7% without; P = .732). No differences were found in the rates of postoperative complications or overall survival at 3 years between the two groups.

Conclusions: Adjunctive peripheral and visceral artery branch interventions in conjunction with TEVAR for acute TBAD with malperfusion occurred in one third of index cases, but did not predispose patients to worse overall outcomes. Adjunctive arterial branch interventions should be included in the treatment paradigm for acute TBAD with end organ malperfusion that does not improve with primary entry tear coverage alone.

Keywords: Aortic dissection; Complicated dissection; Malperfusion; TEVAR; Type B dissection.