In the Journals

TEVAR may be preferable to medical management in certain patients with acute type B aortic dissection

Thoracic endovascular aortic repair had similar or better outcomes compared with medical management in patients with uncomplicated acute type B aortic dissection, according to recent findings.

According to the study background, previous research on thoracic endovascular aortic repair (TEVAR) vs. best medical management in this population was inconsistent.

Yong-Lin Qin, MD, from the department of radiology, Zhongda Hospital, School of Medicine, Southeast University in Nanjing, China, and colleagues conducted a retrospective analysis of 338 patients with uncomplicated acute type B aortic dissection treated within 14 days of onset at three tertiary medical centers between February 2003 and August 2014. TEVAR was performed in 184 patients, and 154 received best medical treatment.

Outcomes of interest included early events (within 30 days of diagnosis); late events (> 30 days after diagnosis); and aortic-related adverse events, including rupture, enlargement of the aorta to more than 60 mm, retrograde type A aortic dissection, ulcer-like projection, endoleak and stent graft-induced new entry.

Early events similar

There was no significant difference in overall early events (TEVAR group, 10.3%; medical group, 4.5%; P = .064) or 30-day mortality (TEVAR group, 0.5%; medical group, 2.6%; P = .18), although there were more minor complications at 30 days in the TEVAR group, driven by type I endoleak (P < .001), according to the researchers.

At 5 years, the rate of aortic-related adverse events was 28.2% in the TEVAR group and 37.8% in the medical-therapy group (P = .025), Qin and colleagues found.

All-cause mortality at 5 years was 10.8% in the TEVAR group vs. 14.3% in the medical-therapy group (P = .01), whereas mortality from aortic-related or unknown causes was 9.2% in the TEVAR group and 12.1% in the medical-therapy group (P = .012).

Late events were higher in the medical-therapy group (38.3% vs. 23.9%; P = .005), driven by aortic enlargement and rupture, according to the researchers.

The study confirmed TEVAR as a feasible option in this population, but “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,” Qin and colleagues wrote.

Controversial report

In a related editorial, Christoph A. Nienaber, MD, PhD, wrote that, “Important aspects of this report are controversial,” including that the TEVAR group had five different stent grafts used during 11 years, that the option of late TEVAR (more than 14 days after dissection) was not included, that crossovers were not mentioned, and that the recommendation for TEVAR in young adults “is tricky because hereditary and connective tissue disorders are more prevalent in the younger population presenting with dissection.”

Christoph A. Nienaber

Nienaber, from the National Institute for Health Research Cardiovascular Biomedical Research Unit of the Royal Brompton and Harefield NHS Trust and Imperial College, London, concluded that, “The data confirmed a long-term benefit from TEVAR in ‘uncomplicated’ type B dissection and solidified the notion of prophylactic TEVAR” but “are not useful to better define ‘uncomplicated’ aortic dissection or stratify our current management.” by Erik Swain

Disclosure: The researchers and Nienaber report no relevant financial disclosures.

Thoracic endovascular aortic repair had similar or better outcomes compared with medical management in patients with uncomplicated acute type B aortic dissection, according to recent findings.

According to the study background, previous research on thoracic endovascular aortic repair (TEVAR) vs. best medical management in this population was inconsistent.

Yong-Lin Qin, MD, from the department of radiology, Zhongda Hospital, School of Medicine, Southeast University in Nanjing, China, and colleagues conducted a retrospective analysis of 338 patients with uncomplicated acute type B aortic dissection treated within 14 days of onset at three tertiary medical centers between February 2003 and August 2014. TEVAR was performed in 184 patients, and 154 received best medical treatment.

Outcomes of interest included early events (within 30 days of diagnosis); late events (> 30 days after diagnosis); and aortic-related adverse events, including rupture, enlargement of the aorta to more than 60 mm, retrograde type A aortic dissection, ulcer-like projection, endoleak and stent graft-induced new entry.

Early events similar

There was no significant difference in overall early events (TEVAR group, 10.3%; medical group, 4.5%; P = .064) or 30-day mortality (TEVAR group, 0.5%; medical group, 2.6%; P = .18), although there were more minor complications at 30 days in the TEVAR group, driven by type I endoleak (P < .001), according to the researchers.

At 5 years, the rate of aortic-related adverse events was 28.2% in the TEVAR group and 37.8% in the medical-therapy group (P = .025), Qin and colleagues found.

All-cause mortality at 5 years was 10.8% in the TEVAR group vs. 14.3% in the medical-therapy group (P = .01), whereas mortality from aortic-related or unknown causes was 9.2% in the TEVAR group and 12.1% in the medical-therapy group (P = .012).

Late events were higher in the medical-therapy group (38.3% vs. 23.9%; P = .005), driven by aortic enlargement and rupture, according to the researchers.

The study confirmed TEVAR as a feasible option in this population, but “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,” Qin and colleagues wrote.

Controversial report

In a related editorial, Christoph A. Nienaber, MD, PhD, wrote that, “Important aspects of this report are controversial,” including that the TEVAR group had five different stent grafts used during 11 years, that the option of late TEVAR (more than 14 days after dissection) was not included, that crossovers were not mentioned, and that the recommendation for TEVAR in young adults “is tricky because hereditary and connective tissue disorders are more prevalent in the younger population presenting with dissection.”

Christoph A. Nienaber

Nienaber, from the National Institute for Health Research Cardiovascular Biomedical Research Unit of the Royal Brompton and Harefield NHS Trust and Imperial College, London, concluded that, “The data confirmed a long-term benefit from TEVAR in ‘uncomplicated’ type B dissection and solidified the notion of prophylactic TEVAR” but “are not useful to better define ‘uncomplicated’ aortic dissection or stratify our current management.” by Erik Swain

Disclosure: The researchers and Nienaber report no relevant financial disclosures.