Thoracic Endovascular Aortic Repair for Type B Aortic Dissection Patients: 11-Year Experience from a Chinese Tertiary Center
Thoracic endovascular aortic repair (TEVAR) has emerged as a mainstream therapy for type B aortic dissection (TBAD), particularly for complicated acute cases. This minimally invasive procedure has gained widespread acceptance due to its favorable clinical outcomes. However, much of the existing knowledge on aortic dissection and endovascular treatment is derived from Western registries, such as the International Registry of Acute Aortic Dissection (IRAD) and the Vascular Quality Initiative (VQI), which include limited representation of Asian populations, particularly Chinese patients. This article presents an 11-year single-center experience of TEVAR for TBAD patients in a high-volume Chinese tertiary center, offering valuable insights into the disease and its management in this population.
Study Design and Patient Population
The study retrospectively analyzed data from TBAD patients who underwent TEVAR at the Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, between 2009 and 2019. Patients were classified into three stages based on the timing of their presentation: acute (1–14 days), subacute (15–90 days), and chronic (>90 days). The general procedure of TEVAR and operative details were consistent with previously published studies from the center. The study was approved by the Institutional Review Board of Zhongshan Hospital, Fudan University.
Clinical Characteristics and Outcomes
A total of 1,573 TBAD patients were included in the study. The mean age of the patients was 56.1 years, with the majority falling within the 50 to 70 years age group. Males constituted 83.2% of the cohort, and 67.9% of the patients had a history of hypertension. Notably, only 38.3% of the patients were covered by local medical insurance.
The aortic-related in-hospital mortality rate was 2.42% (38 of 1,573), and the total incidence of postoperative complications was 8.07% (127 of 1,573). Retrograde type A dissection (RTAD) was the most common cause of in-hospital death, occurring in 15 patients (0.95%), with 10 of these cases resulting in death. Other complications included acute kidney injury (AKI) in 51 patients (3.24%), stroke in 28 patients (1.78%), bowel ischemia in 14 patients (0.89%), and paraplegia in 9 patients (0.57%). RTAD was the leading cause of in-hospital mortality, followed by rupture, bowel ischemia, aorto-esophageal fistula, and other dissection-related complications.
Trends in Mortality and Length of Hospital Stay
Joinpoint regression analyses were performed to examine trends in in-hospital mortality and length of hospital stay (LOS) from 2009 to 2019. While the overall annual in-hospital mortality rate did not show a statistically significant decline, the yearly proportion of mortality in the acute population demonstrated a notable decrease, with an annual percentage change of –12.91%. The average LOS also decreased significantly over the decade, with an annual percentage change of –6.50%. There was no significant difference in LOS between patients who received imported stent grafts (SGs) and those who received domestic SGs (P = 0.9256). Early outcomes were comparable between the two groups.
Risk Factors for In-Hospital Mortality
A generalized linear model was used to evaluate risk factors for aortic-related in-hospital mortality. Patients with a history of hypertension were found to have a higher risk of in-hospital death, with a risk ratio of 3.13 (95% CI: 1.23–7.93). This finding underscores the importance of blood pressure control in TBAD patients, particularly those with a history of hypertension.
Comparison with Previous Studies
The overall incidence of postoperative complications in this study was consistent with previous reports. However, the incidence of paraplegia was relatively low. The aortic-related in-hospital mortality rate of 2.42% was within the range reported in other recent studies (0%–5%) and was notably lower than the 10.6% mortality rate reported in the IRAD 20-year experience. The discrepancy in risk factors for mortality between this study and the IRAD study, which identified low presenting systolic blood pressure (SBP) as an independent risk factor, may be attributed to differences in study focus and patient populations.
Implications for Clinical Practice
The study highlights the favorable early outcomes of TEVAR in TBAD patients over the past decade, with both imported and domestic SGs demonstrating comparable safety and efficacy. The significant reduction in LOS over time reflects advancements in endovascular devices and the accumulation of clinical experience. The identification of hypertension as a risk factor for in-hospital mortality emphasizes the need for rigorous blood pressure management in TBAD patients.
Limitations and Future Directions
While the study provides valuable insights into the management of TBAD in a Chinese population, it has several limitations. The retrospective design may introduce bias, and the single-center nature of the study limits the generalizability of the findings. Long-term follow-up data are needed to further evaluate the outcomes of TEVAR, particularly with respect to the performance of domestic SGs.
Conclusion
This 11-year single-center experience of TEVAR for TBAD patients in a Chinese tertiary center demonstrates favorable early outcomes, with both imported and domestic SGs showing comparable safety and efficacy. The study identifies hypertension as a significant risk factor for in-hospital mortality and highlights the importance of blood pressure control in TBAD patients. The findings contribute to the growing body of knowledge on the management of TBAD in Asian populations and underscore the need for further research to optimize treatment strategies.
doi.org/10.1097/CM9.0000000000001420
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