For better outcomes in the long run, go with thoracic endovascular aortic repair (TEVAR) for uncomplicated Type B aortic dissections, a study suggests.
Patients who only got medical management and those who underwent TEVAR shared similar rates of early events (4.5% versus 10.3%) and 30-day mortality (2.6% versus 0.5%), reported Gao-Jun Teng, MD, of Zhongda Hospital in Nanjing, China, and colleagues.
Yet, as the investigators reported in the Journal of the American College of Cardiology, more than 10 years later the medical therapy group had more aortic-related adverse events than their TEVAR counterparts did. All-cause death was similarly more common in this cohort.
“The long-term prognosis of uncomplicated type B aortic dissection treated with best medical treatment is poor,” the authors concluded.
Survival patterns for the two arms diverged around the 4-year mark. “Given that the TEVAR procedure did not significantly lower morbidity and mortality compared with best medical treatment during the early years of follow-up, TEVAR should be considered as a therapy to improve late outcomes in young adults or patients with longer life expectancy,” according to Teng’s group.
In an accompanying editorial, however, Christoph A. Nienaber, MD, PhD, of London’s Royal Brompton and Harefield NHS Trust, expressed disagreement: “The authors’ conclusion — to offer TEVAR to young adults with ‘uncomplicated’ dissection — is tricky, because hereditary and connective tissue disorders are more prevalent in the younger population presenting with dissection. Patients with both syndromic and nonsyndromic connective tissue disorders are probably not the best candidates for current TEVAR … If in doubt, a connective tissue disorder should reliably be ruled out before considering prophylactic TEVAR,” he warned.
According to the editorialist, “the absence of any ‘high-risk’ feature would justify medical management instead of prophylactic TEVAR, as would unsuitable anatomy and short life expectancy (<2 years).”
“Over the last decade, TEVAR’s safety has improved considerably, but a dissection-specific, dedicated stent graft is still desperately needed, both to avoid occasional complications and to optimize a prophylactic TEVAR strategy,” he added.
The retrospective study by Teng and colleagues included 338 consecutive patients who were treated for uncomplicated type B aortic dissections within 14 days of dissection onset. They received either best medical therapy alone or TEVAR, and baseline characteristics were well matched between the groups. There were three participating centers in China.
Late adverse events (“late” defined as those occurring 30 or more days after diagnosis) such as rupture and aortic enlargement favored the TEVAR arm (23.9% versus 38.3% for the medical arm), as did late deaths (10.2% versus 20.1%).
The investigators acknowledged that their study “had several limitations, including its retrospective nature, different procedural protocols in three hospitals (such as various TEVAR procedure manipulations and medical regimens in different hospitals), and various coverage length of stent grafts selected based on individual preference and local availability.”
Nienaber emphasized the second and third points, writing that “the degree of heterogeneity of TEVAR treatment is high considering the different protocols used in the three centers evaluated, including utilization of five different stent grafts in 184 patients over 11 years (averaging five to six patients per year per center).”
In addition, “the report failed to list both crossovers and missed crossovers from medical management to therapeutic TEVAR or open surgical management during the years of follow-up,” the editorial continued.
“Why should a patient with ‘uncomplicated’ type B aortic dissection receive TEVAR treatment in the acute phase when delayed TEVAR (>14 days from onset) has a lower rate of retrograde proximal dissection as a serious complication? Importantly, postponing TEVAR to the subacute phase could have avoided their one case of retrograde dissection while still allowing ample time for TEVAR-induced remodeling before the window of plasticity/opportunity starts closing about day 100. Why rush when the strategy allows for a fully elective TEVAR including neck vessel debranching, if necessary, for an optimal landing zone?”
Teng did not reply to MedPage Today emails asking for a response to the editorial.
Teng and Nienaber declared no relevant relationships with industry.
Journal of the American College of Cardiology
Qin Y, et al “Endovascular repair compaired with medical management of patients with uncomplicated type B acute aortic dissection” J Am Coll Cardiol 2016; DOI: 10.1016/j.jacc.2016.03.578.
Journal of the American College of Cardiology
Nienaber CA “The art of stratifying patients with type B aortic dissection” J Am Coll Cardiol 2016; DOI: 10.1016/j.jacc.2016.04.016.