© 2014 Wiley Periodicals, Inc.
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DISEASES OF THE AORTA ORIGINAL ARTICLE _____________________________________________________________
Risk Factors of Early and Late Mortality After Thoracic Endovascular Aortic Repair for Complicated Stanford B Acute Aortic Dissection Zhong-Bao Ruan, M.D., Li Zhu, M.D., Yi-Gang Yin, M.D., and Ge-Cai Chen, M.D. Department of Cardiology, Taizhou People’s Hospital, Taizhou, P.R. China ABSTRACT Background and Aim of the Study: The risk factors associated with death in complicated Stanford B acute aortic dissection (AAD) after thoracic endovascular aortic repair (TEVAR) are poorly understood. The aim of this study was to evaluate the early and late events and mortality of complicated Stanford B AAD associated with TEVAR. Methods: Sixty-two patients with complicated Stanford B AAD undergoing TEVAR were included in this study. Results: Primary technical success of TEVAR was achieved in 61 (98.39%) cases. The early mortality rate was 9.68%. Procedural type I endoleak (p = 0.007, OR = 7.71, 95% CI: 1.75–34.01) and cardiac tamponade (p = 0.010, OR = 8.86, 95% CI: 1.70–4 6.14) were the significant predictors of early death in the multivariate model. The late mortality was 16.07%. Cox regression analysis revealed rupture of false lumen (p = 0.001, hazard ratio = 21.96, 95% CI: 3.02–82.12), postoperative myocardial infarction (p = 0.001, hazard ratio = 9.86, 95% CI: 2.12–39.64), and acute renal failure (p = 0.024, hazard ratio = 3.98, 95% CI: 1.26–12.11) to be independent risk factors of late mortality. Conclusions: Type I procedural endoleak and cardiac tamponade were the significant predictors of early death in patients of complicated Stanford B AAD undergoing TEVAR. Rupture of false lumen, postoperative myocardial infarction, and acute renal failure were the independent risk factors for late death after TEVAR. doi: 10.1111/jocs.12377 (J Card Surg 2014;29:501–506) Stanford B acute aortic dissection (AAD) is a lifethreatening medical emergency associated with high rates of morbidity and mortality.1,2 The traditional treatment paradigm of medical management for uncomplicated Stanford B AAD and open surgical intervention for early or late complications of Stanford B AAD is currently undergoing a period of evolution as a result of the influence of minimally invasive thoracic endovascular aortic repair (TEVAR) options. TEVAR is an emerging option to open repair in a selected population with aortic pathologies. Proposed advantages of TEVAR include shorter operative time, less blood loss, decreased need for general anesthesia, and shorter hospital stays. TEVAR has replaced open surgical repair as the preferred treatment for complicated Stanford B AAD.3 Data are limited regarding the effect of recent imaging and therapeutic advances on patient care and outcomes in this setting. Therefore,
Conflict of interest: The authors acknowledge no conflict of interest in the submission. Address for correspondence: Li Zhu, M.D., Department of Cardiology, Taizhou People’s Hospital, Taizhou 225300, P.R. China. Fax: þ86052386225199; e-mail: [email protected]
the exact effect of TEVAR on patients with Stanford B AAD remains unclear or controversial.4,5 In this study, we retrospectively evaluated the effect of TEVAR in treating complicated Stanford B AAD by analyzing the early and late events and mortality associated with this procedure. MATERIALS AND METHODS From March 2004 to January 2009, 62 patients with complicated Stanford B AAD were included in this study. All cases were approved by the hospital’s research ethics committee and identified retrospectively through a review of the hospital admitting notes and radiology departmental procedural logs. Complicated Stanford B AAD was defined as dissection associated with rupture, malperfusion syndromes, refractory pain, or rapid aortic expansion at onset or during the hospital stay.6 Information about baseline characteristics (including age, sex, and history of peripheral arterial disease, hypertension, smoking, diabetes mellitus, renal insufficiency, and coronary artery disease) was collected from the medical records and outpatient clinic notes. Images were retrieved from the imaging archiving system, including initial
502
RUAN, ET AL. RISK FACTORS OF COMPLICATED ACUTE STANFORD B AAD
diagnostic and follow-up computed tomography (CT) angiography scans. Patients were excluded if TEVAR was performed during the chronic phase (14 days), or if they had aortic dissection secondary to trauma, intramural hematoma, complete thrombosis of the false lumen on admission, or Marfan syndrome. For all eligible patients, the thrombosis status of the false lumen was evaluated with CT angiography. The status of the false lumen on imaging was classified as patent if flow was present in the absence of thrombus, as partially thrombosed if both flow and thrombus were present, or as completely thrombosed if no flow was present. The changes of true and false lumen diameter were monitored with CTA examinations in the thoracic aorta at the level of the stented segment at long-term follow-up.
J CARD SURG 2014;29:501–506
(progression of dissection, death, organ failure, stroke, paraplegia, or endoleak) that occurred within 30 days after the initial treatment. A late event was defined as an event associated with the dissection that occurred >30 days after the initial treatment. Late events included rupture, aortic enlargement (>60 mm), retrograde dissection, endoleak, ulcer-like projection (defined as a localized blood-filled pouch protruding from the true lumen into the thrombosed false lumen of the aorta), and late death related to these complications. Follow-up The follow-up physical examination, contrast CT, and laboratory work were performed according to the institutional surveillance protocol at one, six, and 12 months and yearly thereafter for five years.
TEVAR technique All stent grafts were deployed with the common femoral artery approach via unilateral femoral access. When the primary tear was close to the left subclavian artery and/or the left common carotid artery (LCCA), the origins of the left subclavian artery and/or the LCCA were covered by the stent graft. Debranching of the CCA was performed before the procedure by a right CCA–LCCA bypass. An LCCA–left subclavian artery bypass was performed either immediately before or after the TEVAR on the basis of radiographic assessments of vertebrobasilar circulation. Adjunctive stenting of the visceral branches and iliac arteries was performed for static malperfusion when it was deemed necessary on the basis of angiographic evaluation after deployment of the thoracic stent graft. Medical management Antihypertensive medications (calcium-channel blockers, beta-blockers, nitroglycerin, or a combination) were used in all patients with a systolic blood pressure (SBP) >120 mmHg at presentation. In accordance with the treatment protocol of our hospital, nitroglycerin and betablockers were given as a continuous intravenous infusion to maintain a target SBP of 100–120 mmHg, and to relieve pain. Oral antihypertensive therapy was begun two days after the onset of symptoms with beta-blockers, angiotensin-receptor blockers, and/or calcium-channel blockers, as required. Pain was adequately controlled by treatment with nonsteroidal antiinflammatory drugs; if necessary, narcotics were used. After discharge, all patients (TEVAR and medicine group) with hypertension required treatment with calcium antagonists, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, or betablockers, either alone or in combination, to maintain morning SBP
501
DISEASES OF THE AORTA ORIGINAL ARTICLE _____________________________________________________________
Risk Factors of Early and Late Mortality After Thoracic Endovascular Aortic Repair for Complicated Stanford B Acute Aortic Dissection Zhong-Bao Ruan, M.D., Li Zhu, M.D., Yi-Gang Yin, M.D., and Ge-Cai Chen, M.D. Department of Cardiology, Taizhou People’s Hospital, Taizhou, P.R. China ABSTRACT Background and Aim of the Study: The risk factors associated with death in complicated Stanford B acute aortic dissection (AAD) after thoracic endovascular aortic repair (TEVAR) are poorly understood. The aim of this study was to evaluate the early and late events and mortality of complicated Stanford B AAD associated with TEVAR. Methods: Sixty-two patients with complicated Stanford B AAD undergoing TEVAR were included in this study. Results: Primary technical success of TEVAR was achieved in 61 (98.39%) cases. The early mortality rate was 9.68%. Procedural type I endoleak (p = 0.007, OR = 7.71, 95% CI: 1.75–34.01) and cardiac tamponade (p = 0.010, OR = 8.86, 95% CI: 1.70–4 6.14) were the significant predictors of early death in the multivariate model. The late mortality was 16.07%. Cox regression analysis revealed rupture of false lumen (p = 0.001, hazard ratio = 21.96, 95% CI: 3.02–82.12), postoperative myocardial infarction (p = 0.001, hazard ratio = 9.86, 95% CI: 2.12–39.64), and acute renal failure (p = 0.024, hazard ratio = 3.98, 95% CI: 1.26–12.11) to be independent risk factors of late mortality. Conclusions: Type I procedural endoleak and cardiac tamponade were the significant predictors of early death in patients of complicated Stanford B AAD undergoing TEVAR. Rupture of false lumen, postoperative myocardial infarction, and acute renal failure were the independent risk factors for late death after TEVAR. doi: 10.1111/jocs.12377 (J Card Surg 2014;29:501–506) Stanford B acute aortic dissection (AAD) is a lifethreatening medical emergency associated with high rates of morbidity and mortality.1,2 The traditional treatment paradigm of medical management for uncomplicated Stanford B AAD and open surgical intervention for early or late complications of Stanford B AAD is currently undergoing a period of evolution as a result of the influence of minimally invasive thoracic endovascular aortic repair (TEVAR) options. TEVAR is an emerging option to open repair in a selected population with aortic pathologies. Proposed advantages of TEVAR include shorter operative time, less blood loss, decreased need for general anesthesia, and shorter hospital stays. TEVAR has replaced open surgical repair as the preferred treatment for complicated Stanford B AAD.3 Data are limited regarding the effect of recent imaging and therapeutic advances on patient care and outcomes in this setting. Therefore,
Conflict of interest: The authors acknowledge no conflict of interest in the submission. Address for correspondence: Li Zhu, M.D., Department of Cardiology, Taizhou People’s Hospital, Taizhou 225300, P.R. China. Fax: þ86052386225199; e-mail: [email protected]
the exact effect of TEVAR on patients with Stanford B AAD remains unclear or controversial.4,5 In this study, we retrospectively evaluated the effect of TEVAR in treating complicated Stanford B AAD by analyzing the early and late events and mortality associated with this procedure. MATERIALS AND METHODS From March 2004 to January 2009, 62 patients with complicated Stanford B AAD were included in this study. All cases were approved by the hospital’s research ethics committee and identified retrospectively through a review of the hospital admitting notes and radiology departmental procedural logs. Complicated Stanford B AAD was defined as dissection associated with rupture, malperfusion syndromes, refractory pain, or rapid aortic expansion at onset or during the hospital stay.6 Information about baseline characteristics (including age, sex, and history of peripheral arterial disease, hypertension, smoking, diabetes mellitus, renal insufficiency, and coronary artery disease) was collected from the medical records and outpatient clinic notes. Images were retrieved from the imaging archiving system, including initial
502
RUAN, ET AL. RISK FACTORS OF COMPLICATED ACUTE STANFORD B AAD
diagnostic and follow-up computed tomography (CT) angiography scans. Patients were excluded if TEVAR was performed during the chronic phase (14 days), or if they had aortic dissection secondary to trauma, intramural hematoma, complete thrombosis of the false lumen on admission, or Marfan syndrome. For all eligible patients, the thrombosis status of the false lumen was evaluated with CT angiography. The status of the false lumen on imaging was classified as patent if flow was present in the absence of thrombus, as partially thrombosed if both flow and thrombus were present, or as completely thrombosed if no flow was present. The changes of true and false lumen diameter were monitored with CTA examinations in the thoracic aorta at the level of the stented segment at long-term follow-up.
J CARD SURG 2014;29:501–506
(progression of dissection, death, organ failure, stroke, paraplegia, or endoleak) that occurred within 30 days after the initial treatment. A late event was defined as an event associated with the dissection that occurred >30 days after the initial treatment. Late events included rupture, aortic enlargement (>60 mm), retrograde dissection, endoleak, ulcer-like projection (defined as a localized blood-filled pouch protruding from the true lumen into the thrombosed false lumen of the aorta), and late death related to these complications. Follow-up The follow-up physical examination, contrast CT, and laboratory work were performed according to the institutional surveillance protocol at one, six, and 12 months and yearly thereafter for five years.
TEVAR technique All stent grafts were deployed with the common femoral artery approach via unilateral femoral access. When the primary tear was close to the left subclavian artery and/or the left common carotid artery (LCCA), the origins of the left subclavian artery and/or the LCCA were covered by the stent graft. Debranching of the CCA was performed before the procedure by a right CCA–LCCA bypass. An LCCA–left subclavian artery bypass was performed either immediately before or after the TEVAR on the basis of radiographic assessments of vertebrobasilar circulation. Adjunctive stenting of the visceral branches and iliac arteries was performed for static malperfusion when it was deemed necessary on the basis of angiographic evaluation after deployment of the thoracic stent graft. Medical management Antihypertensive medications (calcium-channel blockers, beta-blockers, nitroglycerin, or a combination) were used in all patients with a systolic blood pressure (SBP) >120 mmHg at presentation. In accordance with the treatment protocol of our hospital, nitroglycerin and betablockers were given as a continuous intravenous infusion to maintain a target SBP of 100–120 mmHg, and to relieve pain. Oral antihypertensive therapy was begun two days after the onset of symptoms with beta-blockers, angiotensin-receptor blockers, and/or calcium-channel blockers, as required. Pain was adequately controlled by treatment with nonsteroidal antiinflammatory drugs; if necessary, narcotics were used. After discharge, all patients (TEVAR and medicine group) with hypertension required treatment with calcium antagonists, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, or betablockers, either alone or in combination, to maintain morning SBP
