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J Thorac Cardiovasc Surg 2009;138:300-308
© 2009 The American Association for Thoracic Surgery

Acquired Cardiovascular Disease

Long-term results of percutaneous management of malperfusion in acute type B aortic dissection: Implications for thoracic aortic endovascular repair

^a Department of Surgery, University of Michigan, Cardiovascular Center, Ann Arbor, Mich
^b Department of Radiology, University of Michigan, Cardiovascular Center, Ann Arbor, Mich

Received for publication May 7, 2008; revisions received November 11, 2008; accepted for publication January 10, 2009.

^_* Address for reprints: Himanshu J. Patel, MD, Assistant Professor of Surgery, Section of Cardiac Surgery, 5144 Cardiovascular Center, 1500 E. Medical Center Drive SPC 5864, Ann Arbor, MI 48109-586. (Email: hjpatel{at}med.umich.edu).

Objective: Open repair for acute type B dissection with malperfusion is associated with significant morbidity. Thoracic aortic endovascular repair has been proposed as a less-invasive therapy for acute type B dissection with malperfusion. Benefits of thoracic aortic endovascular repair include the potential for false lumen thrombosis. Its risks include both early morbidity and mortality, and uncertain late results with potentially unstable landing zones. We present the first long-term analysis of an alternative endovascular approach consisting of percutaneous flap fenestration with true lumen and branch vessel stenting to restore end-organ perfusion.

Methods: Outcomes were analyzed for 69 patients presenting with acute type B dissection with malperfusion from 1997 to 2008. All patients were evaluated with angiography and treated with a combination of flap fenestration, true lumen, or branch vessel stenting where appropriate.

Results: Mean age was 57.3 years. Identified malperfused vascular beds included spinal cord (5), mesenteric (40), renal (51), and lower extremity (47). Major morbidity included dialysis need (11), stroke (3), paralysis (2), and 30-day mortality (n = 12, 17.4%). Mean Kaplan–Meier survival was 84.3 months. Although late mortality was associated with age (P < .0001), neither the type nor the number of malperfused vascular beds correlated with vital status at last follow-up (P > .4). Freedom from aortic rupture or open repair at 1, 5, and 8 years was 80.2%, 67.7%, and 54.2%, respectively.

Conclusion: Presentation with acute type B dissection with malperfusion carries a significant risk for both early and late mortality. Percutaneous approaches allow for rapid restoration of end-organ perfusion with acceptable results. These long-term results can serve as comparative data by which to evaluate newer therapies for acute type B dissection with malperfusion, such as thoracic aortic endovascular repair.