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Complicated Acute Type B Dissection: Is Surgery Still the Best Option?

A Report From the International Registry of Acute Aortic Dissection

Rossella Fattori, MD^_*,_*, Thomas T. Tsai, MD, Truls Myrmel, MD, PhD^||, Arturo Evangelista, MD, FESC^¶, Jeanna V. Cooper, MS, Santi Trimarchi, MD, Jin Li, MS, Luigi Lovato, MD^_*, Stephan Kische, MD, Kim A. Eagle, MD, Eric M. Isselbacher, MD^#, Christoph A. Nienaber, MD, FACC, FESC

^_* University Hospital S. Orsola, Bologna, Italy
University of Michigan Medical Center, Ann Arbor, Michigan
Istituto Policlinico San Donato, Milano, Italy
University of Rostock, Rostock, Germany
^|| University Hospital of Tromsø, Tromsø, Norway
^¶ Hospital General Universitario Vall d'Hebron, Barcelona, Spain
^# Massachusetts General Hospital, Boston, Massachusetts.

^_* Reprint requests and correspondence: Dr. Rossella Fattori, Cardiothoracovascular Department, University Hospital S. Orsola, Via Massarenti 9, 40138 Bologna, Italy. (Email: rossella.fattori{at}unibo.it).

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.

Key Words: aorta • survival • surgery • stent-graft

Abbreviations and Acronyms   CI = confidence interval   CVA = cerebrovascular accident   OR = odds ratio

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