Impact of Renin-Angiotensin-Aldosterone System Antagonists on Recovery and Survival After Thoracic Endovascular Aortic Repair for Type B Aortic Dissection.

Abstract

Objectives: Discontinuation of renin-angiotensin-aldosterone system (RAAS) antagonists prior to specific surgeries has been recommended due to their potential association with hypotension-related postoperative complications. However, research on their impact in vascular surgery is limited. This study investigates the association between angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs) and postoperative outcomes following Thoracic Endovascular Aortic Repair (TEVAR) in patients with type B aortic dissection (TBAD).

Methods: Vascular Quality Initiative (VQI) database was utilized to identify all patients who underwent TEVAR for TBAD between January 2014 and March 2025. Patients below the age of 18 and those with connective tissue disorders were excluded. Patients with rupture presentation, type A aortic dissection, and those who required further open thoracotomy were also excluded from the analysis. Our primary outcomes were postoperative myocardial infarction (MI), 30-day, and one-year mortality. Our secondary outcomes were stroke, spinal cord ischemia (SCI), postoperative acute kidney injury, hospital and ICU length of stay, intubation period, and packed red blood cell transfusion. Multivariable logistic regression was used to analyze short-term outcomes while one-year survival was evaluated using Kaplan-Meier estimates with log-rank testing and multivariable Cox proportional hazards modeling.

Results: Of the 5,283 patients who underwent TEVAR for TBAD, 40.2% received preoperative ACE inhibitors or ARBs. These patients were older, had higher rates of hypertension, diabetes, coronary artery disease, congestive heart failure, and cerebrovascular disease, and were more likely to undergo elective procedures. Multivariable analysis showed that preoperative ACEI/ARB use was independently associated with lower SCI risk (aOR 0.72; 95% CI: 0.54-0.96; p=0.024), a reduced need for packed red blood cell transfusions (aOR 0.81, 95% CI 0.69-0.96; p = 0.013), higher odds of same-day extubation (aOR 1.51, 95% CI 1.20-1.91; p < 0.001), and lower odds of prolonged ICU stay (aOR 0.81, 95% CI 0.68-0.97; p = 0.025). ACEI/ARB use was associated with a reduced risk of prolonged hospital stay (aOR 0.84, 95% CI 0.72-0.98; p = 0.027). No significant differences were observed in postoperative MI, postoperative renal dysfunction, or stroke. At one year, ACEI/ARB use was associated with improved survival (adjusted HR 0.84, 95% CI 0.73-0.97; p = 0.022).

Conclusions: This multi-institutional study found that preoperative ACEI/ARB use was associated with reduced spinal cord ischemia risk, transfusion requirements, higher likelihood of same-day extubation, and shorter ICU stays, contributing to improved early postoperative recovery and discharge. Additionally, a significant survival benefit at one year was observed, suggesting a potential role for continuing ACEI/ARB use in patients undergoing TEVAR for TBAD.