Aortic arch involvement worsens the prognosis of type B aortic dissections

R. James Valentine, Julia M. Boll, Kyle M. Hocking, John A. Curci, C. Louis Garrard, Colleen M. Brophy, Thomas C. Naslund

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Abstract

Objective Medical management of acute aortic dissections limited to the descending thoracic aorta (AD-desc) is associated with acceptable outcomes. Uncertainty remains about whether acute type B aortic dissections involving the aortic arch (AD-arch) have an increased risk of retrograde extension into the ascending aorta or other dissection-related complications. This study compared outcomes of AD-arch with AD-desc managed medically. Methods Consecutive patients admitted from 2005 to 2014 with acute aortic dissections not involving the ascending aorta were retrospectively analyzed. Primary end points included dissection-related death and operative intervention. Results The study included 99 patients (63% men; mean age, 60 ± 14 years) with acute aortic dissections. Dissections were limited to the aorta distal to the left subclavian artery (AD-desc) in 79 patients (80%), and 20 (20%) had involvement of the left subclavian (n = 16), left common carotid (n = 1), or innominate (n = 3) arteries (AD-arch). Dissections ended proximal to the celiac artery in 30 patients (30%), between the celiac artery and aortic bifurcation in 36 (36%), and distal to the aortic bifurcation in 33 (33%). During medical management, further proximal extension into the arch occurred in two AD-arch patients and one AD-desc patient (P <.05), but proximal dissection into the ascending aorta occurred in only one AD-arch patient with Marfan disease. Compared with patients with AD-desc, those with AD-arch were younger (53 ± 12.5 vs 62 ± 16 years; P <.01) and had more frequent early interventions (40% vs 19%; P =.047), cardiac complications (35% vs 11%; P <.01), and neurologic events (25% vs 6%; P <.01). Seven AD-arch patients (35%) and nine AD-desc patients (11%) died of dissection-related causes (P <.01). Among survivors, late interventions were performed in four of eight AD-arch patients (50%) and in six of 58 AD-desc patients (10%; P =.02). Medical treatment without intervention was successful in four AD-arch patients (20%) and in 52 AD-desc patients (66%; P <.001). Multivariate logistic regression retained arch involvement as the sole predictor of dissection-related death (odds ratio, 4.2; 95% confidence interval, 1.3-13.4) and failure of medical treatment (odds ratio, 7.7; 95% confidence interval, 2.5-29). The distal extent of dissection had no bearing on outcome. Conclusions AD-arch dissections are associated with a higher risk of cardiac and neurologic events, need for early intervention, and dissection-related death than AD-desc dissections. Because further proximal dissections into the ascending aorta were rare in this study, medical management appears to be safe as the initial treatment of AD-arch dissections. However, surgeons should be aware of the increased risk of complications and the potential need for urgent interventions in these patients.

Original languageEnglish (US)
Pages (from-to)1212-1218
Number of pages7
JournalJournal of Vascular Surgery
Volume64
Issue number5
DOIs
Publication statusPublished - Nov 1 2016

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ASJC Scopus subject areas

  • Surgery
  • Cardiology and Cardiovascular Medicine

Cite this

Valentine, R. J., Boll, J. M., Hocking, K. M., Curci, J. A., Garrard, C. L., Brophy, C. M., & Naslund, T. C. (2016). Aortic arch involvement worsens the prognosis of type B aortic dissections. Journal of Vascular Surgery, 64(5), 1212-1218. https://doi.org/10.1016/j.jvs.2016.04.054