Live from ESVS 2014: TEVAR feasible for ruptured type B dissections

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A study presented at the European Society for Vascular Surgery (ESVS) Annual Meeting (23–25 September 2014, Stockholm, Sweden) shows that thoracic endovascular aneurysm repair (TEVAR) for the treatment of ruptured type B dissections is feasible, and yields an “acceptable” mortality rate of 16.7%.

Elsa Faure, from the Department of Thoracic and Vascular Surgery, University hospital, Montpellier, France, told delegates that reports of TEVAR for complicated acute type B dissection shows a large range of clinical presentations. “With a 50% 30-day mortality rate when managed with open surgery, rupture is the most dramatic complication of acute type B dissections. We investigated the outcomes of TEVAR for acute type B dissection complicated by rupture to assess the results of this particularly critical subgroup,” she said.

In the study, a review of consecutive TEVAR for acute type B dissection in two tertiary centres (Creteil and Montpellier) was performed using a prospectively maintained database.

Between 2000 and 2014, 24 patients (mean age 68 years, 14 males) underwent TEVAR for ruptured acute type B dissection. Sixteen (67%) were in shock (systolic blood pressure <80mmHg) before surgery and 20 required chest drainage for haemothorax. Proximal entry tear was in zone 2 in five and 3 in 18. Six patients required coverage of the left subclavian artery for adequate proximal landing zone, of whom three with concomitant extra-anatomic debranching of the supra-aortic vessels. Technical success was achieved in 100%, and the median length of aortic coverage was 150mm. The 30-day mortality rate was 16.7% (n=4). Two patients (8%) had paraplegia.

Neither stroke nor renal insufficiency requiring new dialysis occurred. During a mean follow-up of 28 months, another death related to dissection occurred and eight patients (33%) required reintervention. All reinterventions were managed by endovascular means.

At the time of the last follow-up CT scan, eight patients (33%) had complete remodelling of the aortic wall.

In conclusion, Faure said, this study confirms the feasibility of TEVAR for ruptured type B aortic dissection and its lower perioperative morbidity and mortality rate compared to open surgery, reducing the 30-day mortality by more than two-thirds. However, the rate of reintervention was high and long-term follow-up is mandatory. She added that coverage of the primary entry tear seemed enough to stop bleeding and reduced the risk of paraplegia.

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