Impact Of Aortic Visceral Branch Vessel Interventions On The Postoperative Outcomes Of Thoracic Endovascular Aortic Repair For Type B Aortic Dissection Complicated With Visceral Malperfusion.

Abstract

Background: Thoracic endovascular aortic repair (TEVAR) is the standard of care for type B aortic dissection (TBAD) complicated with visceral malperfusion. TEVAR is considered efficient at relieving malperfusion caused by dynamic obstruction but not static obstruction, and as such, some patients also require adjunctive visceral branch vessel interventions (VBI). The role of VBI in patients undergoing TEVAR for TBAD complicated with visceral malperfusion is a subject of considerable debate. This study aims to compare the postoperative outcomes of TEVAR with VBI vs without for TBAD complicated with visceral malperfusion in a real-world multi-institutional setting.

Methods: The Society for Vascular Surgery (SVS) Vascular Quality Initiative (VQI) database was queried for patients who underwent TEVAR for TBAD complicated with hepatic, intestinal, or renal malperfusion. The cohort was divided into two groups based on the main exposure variable: TEVAR with adjunctive VBI vs without on either celiac artery (CA), superior mesenteric artery (SMA), right renal artery (RRA), or left renal artery (LRA), presenting with malperfusion. Baseline demographic, clinical, and perioperative characteristics, as well as outcomes such as overall 30-day mortality, malperfusion-related mortality, Major Adverse Cardiovascular Events (MACE: death, myocardial infarction, stroke), overall complications, reinterventions, and visceral branch reinterventions, were compared between the groups. Univariable and multivariable analyses were performed.

Results: Of all reviewed patients, 477 were involved in the final analysis, 324 (67.9%) underwent TEVAR without a VBI, whereas 153 (32.1%) underwent TEVAR in association with an adjunctive intervention on at least one of the visceral branches (CA, SMA, RRA, LRA), presenting with malperfusion. Patients who underwent TEVAR with a VBI had significantly lower rates of overall 30-day mortality (9.8% vs 17.3%, p=0.032), malperfusion-related mortality (3.3% vs 9.6%, p=0.015), a tendency towards a lower rate of MACE (15.7% vs 22.8%, p=0.071), and a higher rate of visceral branch reinterventions (11.8% vs 6.2%, p=0.035). After adjustment for potential confounders, patients who underwent TEVAR with a VBI had 90% decreased odds of 30-day mortality (OR: 0.10, 95%CI: 0.03-0.40, p=0.001), 78% decreased odds of malperfusion-related mortality (OR: 0.22, 95%CI: 0.05-0.95, p=0.043), 50% decreased odds of MACE (OR: 0.50, 95%CI: 0.25-0.97, p=0.040) and increased odds of visceral branch reinterventions (OR: 2.36, 95%CI: 1.01-5.52, p=0.047).

Conclusions: TEVAR with VBI is associated with significantly reduced odds of 30-day mortality, malperfusion-related mortality, and MACE, but increased odds of visceral branch reinterventions in TBAD patients presenting with visceral malperfusion. Based on these results, a lower threshold for performing VBI is recommended for patients with malperfusion. Further prospective studies are required to confirm these findings and to identify patients who would benefit from VBI the most.