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Published on: March 28, 2025
Intervention rates and outcomes in medically managed uncomplicated descending thoracic aortic dissections
Maximilian Kreibich1, Matthias Siepe1, Tim Berger1
1Faculty of Medicine, Department of Cardiovascular Surgery, University Heart Center Freiburg, Albert-Ludwigs-University of Freiburg, Freiburg, Germany.
Insights
A significant number of patients with uncomplicated descending aortic dissections require further aortic interventions. Key predictors include larger aortic diameters and dissection length, necessitating a range of treatment options.
Area of Science:
- Cardiovascular Surgery
- Vascular Surgery
- Thoracic Surgery
Background:
- Thoracic aortic dissection (TAD) management strategies are evolving.
- Uncomplicated cases are often managed medically, but long-term outcomes require evaluation.
- Identifying patients at risk for intervention is crucial for timely management.
Purpose of the Study:
- To assess the long-term incidence and outcomes of aortic interventions in patients with initially medically managed, uncomplicated descending aortic dissections.
- To identify predictors of aortic intervention in this patient cohort.
- To analyze the risk of intervention over time.
Main Methods:
- Retrospective analysis of 91 patients with uncomplicated descending aortic dissections (January 2012-December 2018).
- Comparison of patient characteristics, imaging, treatment, and follow-up data between those who did and did not require aortic intervention.
- Competing risk regression modeling to identify independent predictors and risk for intervention.
Main Results:
- 33% of patients required aortic intervention after a median of 4 months.
- Intervention was associated with larger thoracic/abdominal aortic diameters, longer dissections, and more intimal communications.
- Descending thoracic aortic diameter >45 mm predicted intervention (SHR: 3.51).
- 1- and 3-year intervention risks were 27% and 36%, respectively. Various endovascular, hybrid, and open surgical techniques were employed without in-hospital mortality.
Conclusions:
- A substantial proportion of patients with initially medically managed, uncomplicated descending aortic dissections necessitate secondary aortic interventions.
- Predictive factors for intervention include aortic diameter and dissection characteristics.
- A comprehensive approach utilizing the full spectrum of aortic repair strategies is essential for managing these complex cases.
Objective:
To evaluate the long-term incidence and outcome of aortic interventions for medically managed uncomplicated thoracic aortic dissections.
Methods:
Between January 2012 and December 2018, 91 patients were discharged home with an uncomplicated, medically treated aortic dissection (involving the descending aorta with or without aortic arch involvement, no ascending involvement). After a median period of 4 (first quartile: 2, third quartile: 11) months, 30 patients (33%) required an aortic intervention. Patient characteristics, radiographic, treatment, and follow-up data were compared for patients with and without aortic interventions. A competing risk regression model was analyzed to identify independent predictors of aortic intervention and to predict the risk for intervention.
Results:
Patients who underwent aortic interventions had significantly larger thoracic (P = .041) and abdominal (P = .015) aortic diameters, the dissection was significantly longer (P = .035), there were more communications between both lumina (P = .040), and the first communication was significantly closer to the left subclavian artery (P = .049). A descending thoracic aortic diameter exceeding 45 mm was predictive for an aortic intervention (P = .001; subdistribution hazard ratio: 3.51). The risk for aortic intervention was 27% ± 10% and 36% ± 11% after 1 and 3 years, respectively. Fourteen patients (47%) underwent thoracic endovascular aortic repair, 11 patients (37%) thoracic endovascular aortic repair and left carotid to subclavian bypass, 3 patients (10%) total arch replacement with the frozen elephant trunk technique, and 2 patients (7%) thoracoabdominal aortic replacement. We observed no in-hospital mortality.
Conclusions:
The need for secondary aortic interventions in patients with initially medically managed, uncomplicated descending aortic dissections is substantial. The full spectrum of aortic treatment options (endovascular, hybrid, conventional open surgical) is required in these patients.
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