Colin Ryan, Tara M. Mastracci, Matthew J. Eagleton, Sunita Srivastava, Rebecca Kelso, Sean Lyden, Daniel G. Clair, Timur Sarac
Vascular Surgery, The Cleveland Clinic, Cleveland, OH.
OBJECTIVES: Malperfusion syndrome is a known predictor of poor outcome in acute type B dissection. We describe our experience with endovascular revascularization in the acute setting.
METHODS: Consecutive patients undergoing intervention for malperfusion or branch vessel ischemia presenting with acute type B dissection between 6/2003 and 3/2011 were reviewed. Details of the presenting condition, surgical intervention, and postoperative course were collected. Descriptive and inferential statistical analyses were planned including survival and freedom from reintervention analysis using a Cox proportional hazards model.
RESULTS: A total of 61 patients were identified with malperfusion in at least one territory, including spinal cord in 7/61 (12%) mesenteric in 37/61 (61%), renal in 45/61 (73%) and lower extremity in 38/61 (62%). Thoracic stent grafts were placed in all patients, and 41% of patients required adjunctive branch vessel stenting. After intervention, resolution of the ischemia was reported in 57/61 (93%) of patients. The 30-day/in hospital mortality was 21.3%. The 6 month, 1 year and 5 year survival was 75% (95% confidence interval [CI] –65-87), 71% (95% CI –61-84) and 56% (95% CI – 43-74), respectively. The 6-month, 1-year and 5-year freedom from reintervention was 84% (95% confidence interval [CI] –75-95), 76% (95% CI –65-90) and 42% (95% CI –24-76), respectively. Territory of ischemia was not independently associated with mortality, but placement of stent graft proximal to the subclavian artery was associated with poor outcome (HR 2.91 (95% CI 1.09-8.11; p=0.034).
CONCLUSIONS: Malperfusion in any territory at the time of presentation in patients with type B dissections can be treated with endovascular intervention with acceptable outcomes. The extent of aortic intervention, as opposed to branch intervention alone, may signify more serious disease, and as such is associated with worse outcome.
AUTHOR DISCLOSURES: D. G. Clair, Endologix, Consulting fees or other remuneration (payment); M. J. Eagleton, Cook, Speaker’s bureau; R. Kelso, Nothing to disclose; S. Lyden, Medtronic, Consulting fees or other remuneration (payment); T. M. Mastracci, Cook, Speaker’s bureau; C. Ryan, Nothing to disclose; T. Sarac, AAA patents, Ownership or Partnership; S. Srivastava, Nothing to disclose.
Posted April 2012