Timing of Endovascular Repair Impacts Long-term Outcomes of Uncomplicated Acute Type B Aortic Dissection

Abstract Objective To compare 5-year outcomes of acute versus subacute thoracic endovascular aortic repair (TEVAR) in patients with uncomplicated acute type B aortic dissection (ATBAD). Methods Between March 2008 and September 2018, 238 consecutive patients with uncomplicated ATBAD received the TEVAR treatment in the acute or subacute phase were retrospectively analyzed. The primary endpoints were all-cause death and aortic-related death. The second endpoint was composite outcomes of death from any cause, rupture, new dissection, retrograde type A aortic dissection, endoleak, and late reintervention. Inverse probability treatment weighting (IPTW) was used to balance baseline characteristics. Weight-adjusted Kaplan–Meier estimate with landmark analysis and weighted Cox model were performed to assess time-to-event outcomes. Results In the IPTW-adjusted population, the 30-day mortality was 1.5% in the acute TEVAR group and 0% in the subacute TEVAR group (P = .24). The incidence of 30-day adverse events occurred in 16.8% and 6.9% patients in the acute TEVAR and subacute TEVAR group, respectively (P = .13). At 5 years, there was no statistically significant difference in all-cause death (hazard ratio [HR], 1.50; 95% confidence interval [CI], 0.59-3.81; P = .39) and aortic-related death (HR, 1.11; 95% CI, 0.34-3.60; P = .86) between two groups. The composite outcomes occurred in 30 (23.0%) patients in the acute TEVAR group and 18 (22.3%) patients in the subacute TEVAR group, respectively (HR, 0.67; 95% CI, 0.36-1.25; P = .20). However, landmark analysis of the composite outcomes indicated that there was a significant interaction between treatment effect and time (Pinteraction = .01), with a significantly higher incidence of the composite outcomes in the acute TEVAR group compared with the subacute TEVAR group within 1 year (HR, 0.25; 95% CI, 0.08-0.79; P = .02) but a comparable rate between 1 and 5 years (HR, 1.25; 95% CI, 0.56-2.76; P = .59). Conclusions At 5-year follow-up, no significant differences exist in the all-cause death and aortic-related death between acute and subacute TEVAR. However, acute TEVAR is associated with an increased rate of severe complications within 1 year which suggests performing TEVAR in the subacute phase of ATBAD may be the preferable option.