Issue: November 2010
November 01, 2010
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Reduced in-hospital mortality reported in patients undergoing endovascular repair for TBAD

Sachs T. J Vasc Surg. 2010;52:860-866.

Issue: November 2010
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Patients who underwent thoracic endovascular aortic repair for Stanford type B acute aortic dissections when compared with open repair had lower rates of in-hospital mortality, despite having greater comorbidities, study results indicated.

The Boston-based researchers involved with the study examined records of the Nationwide Inpatient Sample database between 2005 and 2007. Patients were excluded if they had an ICD code for aortic aneurysm and procedure codes for cardioplegia or for operations on heart vessels or valves, which were considered type A thoracic aortic dissections (TAAD). The remaining patients were considered type B thoracic aortic dissection (TBAD).

Of the total repairs (n=10,466) for dissection of the thoracic or thoracoabdominal aorta, 5,000 were considered TBAD, which researchers grouped into two arms: open (n=3,619) and thoracic endovascular aortic repair (TEVAR, n=1,381). Comorbidities were higher in the TEVAR group, with cardiac disease, renal failure, hypertension and peripheral vascular disease reaching statistical significance.

Overall, in-hospital mortality rates of the TEVAR group were 10.6% vs. 19% in the open repair group (OR=2.24; 95% CI, 1.36-3.67), with rates significantly higher with open repairs coded as emergent admissions (20.1% vs. 13.1%, P=.03).

Additional study data showed higher rates of cardiac complications (12.4% vs. 4.9%; P<.01), respiratory complications (7.7% vs. 4.3%, P=.02), genitourinary complications (9% vs. 2.5%, P<.01), hemorrhage (14% vs. 2.8%, P<.01) and acute renal failure (32.1% vs. 17.2%, P<.01) in the open repair group.

Several limitations were noted by researchers, including the possibility for cofounding, the unlikelihood of being able to exclude all TAAD and the inability to specifically quantify or distinguish the complexity of presenting symptoms or anatomic variations of the individual patients.

“Despite these limitations, we believe this study is valuable because it demonstrates that approximately 25% of repairs for TBAD are TEVAR,” the researchers wrote. “The endovascular approach is being used for older patients, with greater comorbidities, and shows reduced morbidity and mortality, and does so at less cost and shorter hospital stay. Although there are limitations to our data, those patients identified as emergent admissions are likely to have acute dissections, and TEVAR mortality in this TEVAR subgroup — although higher than what was reported in the IRAD study — is still lower than what was seen with open repair.”

In a discussion accompanying the study, Christopher J. Kwolek, MD, assistant professor of surgery, Harvard Medical School, Boston, said the study helps broaden current understanding of what is occurring nationally in the open and endovascular management of TBAD.

“These results agree with the data presented by the European Collaborators on Stent-Graft Techniques for Aortic Aneurysm Repair (EUROSTAR) collaborators and several small single-center series,” Kwolek wrote. “Our practice at the Massachusetts General Hospital also utilizes TEVAR as the first-line therapy for the management of acute complicated type B aortic dissection in conjunction with endovascular fenestration and stenting of the visceral and iliac vessels as necessary.”

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