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Timing and Outcome of Endovascular Repair for Uncomplicated Type B Aortic Dissection

  • Author Footnotes
    ‡ Enmin Xie and Fan Yang contributed equally to this work.
    Enmin Xie
    Footnotes
    ‡ Enmin Xie and Fan Yang contributed equally to this work.
    Affiliations
    Department of Cardiology, Vascular Centre, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People’s Republic of China

    The Second School of Clinical Medicine, Southern Medical University, Guangzhou, People’s Republic of China
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  • Author Footnotes
    ‡ Enmin Xie and Fan Yang contributed equally to this work.
    Fan Yang
    Footnotes
    ‡ Enmin Xie and Fan Yang contributed equally to this work.
    Affiliations
    Department of Emergency and Critical Care Medicine, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People’s Republic of China
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  • Yuan Liu
    Affiliations
    Department of Cardiology, Vascular Centre, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People’s Republic of China
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  • Ling Xue
    Affiliations
    Department of Cardiology, Vascular Centre, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People’s Republic of China
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  • Ruixin Fan
    Affiliations
    Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People’s Republic of China
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  • Nianjin Xie
    Affiliations
    Department of Cardiology, Vascular Centre, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People’s Republic of China
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  • Lyufan Chen
    Affiliations
    Department of Cardiology, Vascular Centre, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People’s Republic of China
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  • Jitao Liu
    Affiliations
    Department of Cardiology, Vascular Centre, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People’s Republic of China
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  • Jianfang Luo
    Correspondence
    Corresponding author. Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, #96 Dongchuan Road, Yuexiu District, Guangzhou, Guangdong, 510080, People’s Republic of China.
    Affiliations
    Department of Cardiology, Vascular Centre, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People’s Republic of China

    The Second School of Clinical Medicine, Southern Medical University, Guangzhou, People’s Republic of China
    Search for articles by this author
  • Author Footnotes
    ‡ Enmin Xie and Fan Yang contributed equally to this work.
Open ArchivePublished:April 10, 2021DOI:https://doi.org/10.1016/j.ejvs.2021.02.026

      Objective

      This study aimed to determine the effect of intervention timing, from symptom onset to thoracic endovascular aortic repair (TEVAR), on early and late outcomes in high risk patients with uncomplicated type B aortic dissection (uTBAD).

      Methods

      The study retrospectively evaluated 267 uTBAD patients with high risk radiographic features who underwent pre-emptive TEVAR during the acute and subacute periods. Demographics, comorbidities, pre-operative imaging features, peri-procedural details, and follow up outcomes were analysed.

      Results

      Among the 267 pre-emptive TEVARs for high risk uTBAD, 130 were performed in the acute phase (1–14 days); and 137 in the subacute phase (15–90 days), from initial presentation. The mean age was 55.9 ± 11.0 years and 222 (83.1%) were men. The 30 day mortality rate in the acute group was five times higher than that in the subacute group (3.8% vs. 0.7%), although without statistically significant difference (p = .11). No statistically significant difference in 30 day outcomes (aortic rupture, retrograde type A dissection [RTAD], immediate type Ia endoleak, stroke, spinal cord ischaemia, and re-intervention) was noted (p > .05 for each). Of note, aortic rupture, RTAD, and disabling stroke were observed only in the acute group. Multivariable logistic analyses showed that intervention timing was not associated with 30 day outcomes. The median clinical follow up was 48.2 ± 25.9 months (range 1 – 106 months). There were no significant differences in all cause mortality, dissection related death, late intervention, or aortic related late events among timing cohorts (p > .05 for each). Furthermore, aortic remodelling, by analysing the flow status of the false lumen and evaluation of aortic diameters, either at the thoracic aorta level or the abdominal aorta level, was similar between the two groups. Multivariable Cox analyses showed that intervention timing was not associated with late outcomes.

      Conclusion

      The present study indicates that TEVAR for high risk uTBAD in the acute phase was associated with a trend toward higher rates of early complications, while the long term outcomes were comparable with those of the subacute phase.

      Keywords

      Thoracic endovascular aortic repair (TEVAR) can be used in uncomplicated type B aortic dissection (uTBAD) to improve long term outcomes, but the impact of intervention timing remains unclear. The present study found no significant difference in early or late outcomes between acute (1–14 days) and subacute (15–90 days) groups. Although not statistically significant, 30 day mortality in the acute group was five times higher, and aortic rupture, retrograde type A dissection, and disabling stroke were observed only in the acute group. These results suggest caution in endovascular repair for uTBAD patients in the acute phase.

      Introduction

      Thoracic endovascular aortic repair (TEVAR) is now routinely used in complicated type B aortic dissection (cTBAD).
      • Erbel R.
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      • et al.
      2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC).
      ,
      • Riambau V.
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      • et al.
      Editor's Choice - Management of Descending Thoracic Aorta Diseases: Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS).
      For uncomplicated type B aortic dissection (uTBAD), current guidelines state that best medical treatment (BMT) should always be recommended. However, long term outcomes of BMT alone were unsatisfactory, with the rate of aortic related complications up to 50% at five years.
      • Hughes G.C.
      • Andersen N.D.
      • McCann R.L.
      Management of acute type B aortic dissection.
      • Qin Y.L.
      • Wang F.
      • Li T.X.
      • Ding W.
      • Deng G.
      • Xie B.
      • et al.
      Endovascular Repair compared with medical management of patients with uncomplicated Type B acute aortic dissection.
      • Iannuzzi J.C.
      • Stapleton S.M.
      • Bababekov Y.J.
      • Chang D.
      • Lancaster R.T.
      • Conrad M.F.
      • et al.
      Favorable impact of thoracic endovascular aortic repair on survival of patients with acute uncomplicated type B aortic dissection.
      With favourable results in patients with cTBAD, the use of TEVAR has expanded to patients with uTBAD.
      • Tadros R.O.
      • Tang G.
      • Barnes H.J.
      • Mousavi I.
      • Kovacic J.C.
      • Faries P.
      • et al.
      Optimal treatment of uncomplicated Type B aortic dissection: JACC Review Topic of the Week.
      Currently, guidelines suggest that pre-emptive TEVAR should be considered in selected patients who are at high risk of further aortic complications.
      • Erbel R.
      • Aboyans V.
      • Boileau C.
      • Bossone E.
      • Bartolomeo R.D.
      • Eggebrecht H.
      • et al.
      2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC).
      ,
      • Riambau V.
      • Bockler D.
      • Brunkwall J.
      • Cao P.
      • Chiesa R.
      • Coppi G.
      • et al.
      Editor's Choice - Management of Descending Thoracic Aorta Diseases: Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS).
      However, the optimal timing of intervention remains uncertain.
      Early intervention could attenuate the progressive aortic pathology (rupture, malperfusion, and aneurysmal degeneration), but appears to increase peri-operative complication rates because of the fragile intima of the inflamed aorta.
      • Desai N.D.
      • Gottret J.P.
      • Szeto W.Y.
      • McCarthy F.
      • Moeller P.
      • Menon R.
      • et al.
      Impact of timing on major complications after thoracic endovascular aortic repair for acute type B aortic dissection.
      The VIRTUE registry showed that the dissected aorta retained its plasticity after the classical two week window, and thus suggested a delay of two weeks or longer for TEVAR for uTBAD.
      Virtue Registry Investigators. Mid-term outcomes and aortic remodelling after thoracic endovascular repair for acute, subacute, and chronic aortic dissection: the VIRTUE Registry.
      Data from the Society for Vascular Surgery Vascular Quality Initiative thoracic endovascular aortic repair for type B dissection project (SVS VQI TEVAR surveillance project) demonstrated that no difference in 30 day outcomes existed based on timing of TEVAR in patients with uTBAD
      • Wang G.J.
      • Cambria R.P.
      • Lombardi J.V.
      • Azizzadeh A.
      • White R.A.
      • Abel D.B.
      • et al.
      Thirty-day outcomes from the Society for Vascular Surgery Vascular Quality Initiative thoracic endovascular aortic repair for type B dissection project.
      ; however, that study was based on a relatively small sample and lacked information on long term outcomes. The purpose of this retrospective study was to investigate the effect of intervention timing, from symptom onset to TEVAR, on early and late outcomes in a Chinese high risk uTBAD cohort.

      Materials and methods

      Study population

      Between January 2010 and December 2017, 857 consecutive patients with TBAD who underwent TEVAR during the acute and subacute periods at the study centre were reviewed retrospectively through medical records, with 341 patients with uTBAD. The type B aortic dissection (TBAD) was diagnosed by contrast enhanced computed tomography angiography (CTA) according to the criteria of Stanford classification. Patients with malignant tumours, connective diseases, or proximal landing zone 1, were excluded from this study. The remaining 267 patients with uTBAD were included in the analysis (Fig. 1). Patients were divided into two groups based on time interval from symptom onset to TEVAR: an acute group (1–14 days; n = 130) and a subacute group (15–90 days; n = 137). During the study period, 332 patients with uTBAD were treated conservatively because of the absence of high risk radiographic features, or eligible patient refusal, with a 0.6% 30 day mortality rate.
      Figure 1
      Figure 1Flow diagram of the included population of high risk uncomplicated type B aortic dissection patients treated by thoracic endovascular aortic repair.
      Ethical approval for this study was obtained from Guangdong Provincial People’s Hospital Ethics Committee and informed consent was waived as it was a retrospective study.

      Indication for thoracic endovascular aortic repair

      All patients with uTBAD were evaluated by a multidisciplinary team comprising cardiologists, endovascular surgeons, cardiovascular surgeons, radiologists, and anaesthetists. The maximum diameter of the aorta, the size of primary entry tear, extent of dissection, false lumen status, and visceral artery involvement were evaluated by dedicated Aquarius iNtuition software (Terarecon, San Mateo, CA, USA). The considerations for pre-emptive TEVAR included aortic diameter > 40 mm, false lumen (FL) diameter > 22 mm, a patent or partial thrombosed FL, and primary entry tear diameter > 10 mm.
      • Evangelista A.
      • Salas A.
      • Ribera A.
      • Ferreira-Gonzalez I.
      • Cuellar H.
      • Pineda V.
      • et al.
      Long term outcome of aortic dissection with patent false lumen: predictive role of entry tear size and location.
      • Marui A.
      • Mochizuki T.
      • Koyama T.
      • Mitsui N.
      Degree of fusiform dilatation of the proximal descending aorta in type B acute aortic dissection can predict late aortic events.
      • Song J.M.
      • Kim S.D.
      • Kim J.H.
      • Kim M.J.
      • Kang D.H.
      • Seo J.B.
      • et al.
      Long term predictors of descending aorta aneurysmal change in patients with aortic dissection.
      • Tsai T.T.
      • Evangelista A.
      • Nienaber C.A.
      • Myrmel T.
      • Meinhardt G.
      • Cooper J.V.
      • et al.
      Partial thrombosis of the false lumen in patients with acute type B aortic dissection.
      • Akutsu K.
      • Nejima J.
      • Kiuchi K.
      • Sasaki K.
      • Ochi M.
      • Tanaka K.
      • et al.
      Effects of the patent false lumen on the long term outcome of type B acute aortic dissection.
      After confirming eligibility, an explanation about the possible risks and benefits of different managements (BMT vs. TEVAR) was provided to patients and their families. The final decision for TEVAR was made by the consensus of patients and their families with fully informed consent.

      Timing for thoracic endovascular aortic repair

      During the study period, pre-emptive TEVAR was performed for patients with uTBAD without a specific time point, except not on the first day. The reasons were listed as follows. First, patients with uTBAD were considered to be relatively “stable”, as defined, and less prone to complications. Second, a very early study
      • Sayer D.
      • Bratby M.
      • Brooks M.
      • Loftus I.
      • Morgan R.
      • Thompson M.
      Aortic morphology following endovascular repair of acute and chronic type B aortic dissection: implications for management.
      found that patients with acute aortic dissection (within two weeks) demonstrated significant aortic remodelling, whereas patients with chronic aortic dissection (greater than two weeks) did not. Third, it was considered that patients with uTBAD within the first 24 hours might be associated with peri-operative complications because of the fragility of the freshly dissected aorta. This hypothesis was also validated by subsequent studies.
      • Desai N.D.
      • Gottret J.P.
      • Szeto W.Y.
      • McCarthy F.
      • Moeller P.
      • Menon R.
      • et al.
      Impact of timing on major complications after thoracic endovascular aortic repair for acute type B aortic dissection.
      In addition, patients with uTBAD did not require emergency TEVAR (within the first 24 hours) as there were no life threatening complications. As a result, the timing, from symptom onset to TEVAR, mainly depended on the interval from symptom onset to admission and to the time of decision making by patients and families. Once patients with uTBAD were admitted to the centre and gave consent to TEVAR, the procedures were performed as soon as possible.

      Procedures

      The standardised procedure for TEVAR was described in a previous study.
      • Ding H.
      • Liu Y.
      • Xie N.
      • Fan R.
      • Luo S.
      • Huang W.
      • et al.
      Outcomes of chimney technique for preservation of the left subclavian artery in Type B aortic dissection.
      ,
      • Zhu Y.
      • Luo S.
      • Ding H.
      • Liu Y.
      • Huang W.
      • Xie N.
      • et al.
      Predictors associated with an increased prevalence of postimplantation syndrome after thoracic endovascular aortic repair for type B aortic dissection.
      The procedures were performed in a cardiac catheterisation room generally under local anaesthesia. All thoracic stent grafts were delivered retrograde to cover the primary entry tear via femoral artery access with pre-closing technique. The stent graft diameter was generally oversized to the non-dissected aortic maximum dimension in the proximal landing zone by 5% to 10% for patients without a chimney stent, but 10% to 15% for patients with a chimney stent. For patients who required proximal landing zone 2, the revascularisation of the left subclavian artery (LSA) was left to the discretion of the TEVAR team based on radiographic assessments of the vertebrobasilar circulation. In this study, the LSA was revascularised by chimney technique or left common carotid artery (LCCA) to LSA bypass. A sheath was introduced into the left radial (6 F) or left brachial artery (7 to 9 F) depending on the size of chimney graft, through which a stiff guide wire was inserted into the ascending thoracic aorta. The chimney graft was deployed parallel to the aortic stent graft with a > 2.0 cm proximal segment in the aortic lumen and the distal segment in the LSA for patients without an isolated left vertebral artery (ILVA), and > 1.0 cm for patients with an ILVA. The LCCA to LSA bypass was performed prior to TEVAR in a hybrid operating room under general anaesthesia and cerebral flow monitoring by cerebral oximetry. Gore-Tex suture and Gore-Tex vascular grafts (W. L. Gore & Associates, Flagstaff, AZ, USA) were used during the study period. Finally, completion angiography was performed to assess the positions of the stent grafts and to detect immediate endoleaks. Cerebrospinal fluid drainage (CSF) was used selectively when the patient was considered to be at increased risk of spinal cord ischaemia, including planned two aortic stent graft insertions, or when spinal cord ischaemia was suspected (e.g., sensorimotor abnormalities in the lower limbs).

      Follow up

      Survival and clinical evaluation were gathered via outpatient clinic and telephone interviews. CTA was performed at one, three, six and 12 months post-operatively, and yearly thereafter. Patients underwent clinical and imaging evaluation at corresponding intervals. The follow up imaging could be conducted in any hospital, with the results of re-examinations evaluated by two independent physicians. For the present study, patients were followed up until 30 October 2019. Information on baseline demographic characteristics, comorbidities, pre-operative imaging features, TEVAR procedural details, and follow up outcomes was gathered and analysed. Aortic remodelling was evaluated by analysing the flow status of the FL in the thoracic and abdominal aorta, and by evaluation of the aortic diameters at thoracic and abdominal levels during the follow up period. The boundary of the thoracic and abdominal aorta was the diaphragm.

      Definitions

      “Uncomplicated” was characterised as no evidence of refractory pain, uncontrolled hypertension despite full medication, rapid aortic expansion, malperfusion syndromes, and signs of rupture (haemothorax, increasing peri-aortic and mediastinal haematoma). “High risk” was defined as patients with high risk radiographic features, including initial false lumen diameter of ≥ 22 mm, a maximum aortic diameter of ≥ 40 mm, a patent or partially thrombosed FL, and an initial entry tear of ≥ 10 mm. Outcomes were reported subject to the reporting standards for TEVAR
      • Fillinger M.F.
      • Greenberg R.K.
      • McKinsey J.F.
      • Chaikof E.L.
      Reporting standards for thoracic endovascular aortic repair (TEVAR).
      and the reporting standards for TBAD.
      • Lombardi J.V.
      • Hughes G.C.
      • Appoo J.J.
      • Bavaria J.E.
      • Beck A.W.
      • Cambria R.P.
      • et al.
      Society for Vascular Surgery (SVS) and Society of Thoracic Surgeons (STS) reporting standards for type B aortic dissections.
      “Primary technical success” was defined as complete coverage of the primary entry tear in the absence of type I or III endoleaks at the end of the procedure, graft obstruction, or death within 24 hours. Early events were defined as mortality and morbidity within 30 days after TEVAR. All early deaths were considered to be dissection related. Late events were defined as mortality and morbidity that occurred more than 30 days after TEVAR. Aortic related late events included dissection related death, aortic rupture, retrograde type A dissection (RTAD), stent graft induced new entry tear (SINE), re-intervention, and any endoleaks. Late re-intervention was defined as any unplanned re-TEVAR or open surgery beyond 30 days post-operatively, because of complications of the index TEVAR, device failure, or progression of the dissection process.

      Statistical analysis

      Continuous variables are given as mean ± standard deviation or as the median and interquartile range (range from the 25th to the 75th percentile) and compared by Student t test or Mann–Whitney test as appropriate. Categorical variables are presented as percentages, analysed with Fisher’s exact or χ
      • Riambau V.
      • Bockler D.
      • Brunkwall J.
      • Cao P.
      • Chiesa R.
      • Coppi G.
      • et al.
      Editor's Choice - Management of Descending Thoracic Aorta Diseases: Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS).
      test. Kaplan–Meier and life table analyses were conducted to calculate the rates of all cause death, dissection related death, late intervention, and aortic related late events. Log rank tests were used to discriminate between the Kaplan–Meier curves except for dissection related death, which was analysed with Gray’s test (with other reason caused death as a competing event). To assess the impact of timing (acute vs. subacute) on outcomes, univariable and multivariable logistic regression models were built for early outcomes, and Cox regression models for long term outcomes. Power was calculated at a two sided α error of .05. Data analyses were conducted using the SPSS 23.0 (IBM SPSS 23 Inc) and R 3.6.1 (R Development Core Team, Vienna, Austria).

      Results

      Baseline characteristics and details for thoracic endovascular aortic repair intervention

      Overall, 222 (83.1%) patients were men, with a mean age of 55.4 ± 11.1 years (range 34 – 81 years), while 45 (16.9%) were women, with a mean age of 57.9 ± 10.2 years (range 36 – 81 years). The most common comorbidity was hypertension (210; 78.7%). No statistically significant differences were found in demographics, comorbidity profiles, and pre-operative CTA features among timing cohorts (Table 1). Of note, 171 (64.0%) patients showed more than one high risk radiographic feature mainly because all patients with a patent FL experienced other high risk radiographic features. The annual number of TEVARs is shown in Fig. S1, with no significant difference between the two groups (p = .70). The LSA was covered in 145 (54.3%) patients, with 68 (25.5%) receiving chimney stents, 14 (5.2%) receiving LCCA to LSA bypass, and the rest of the patients not requiring revascularisation because of adequate vertebrobasilar circulation. More procedure details are presented in Table 2; there were no significant differences between timing cohorts.
      Table 1Demographic data of 267 patients and computed tomography angiography (CTA) imaging features of uncomplicated type B aortic dissection before thoracic endovascular aortic repair
      Acute intervention (n = 130)Subacute intervention (n = 137)p
      Age – y55.7 ± 11.156.0 ± 10.9.83
      Male sex107 (82.3)115 (83.9).72
      Hypertension105 (80.8)105 (76.6).41
      Diabetes mellitus7 (5.4)10 (7.3).52
      Hyperlipidaemia13 (10.0)17 (12.4).53
      Cerebrovascular disease5 (3.8)9 (6.6).32
      Coronary artery disease22 (16.9)25 (18.2).78
      COPD2 (1.5)3 (2.2)1.0
      Chronic kidney disease18 (13.8)11 (8.0).13
      Current smoker57 (43.8)51 (37.2).27
      Transfer status104 (80.0)99 (72.3).14
      Pre-operative CTA features
       Size of primary entry tear – mm8.5 ± 5.19.2 ± 7.5.33
      Re-entry tear.57
      061 (46.9)73 (53.3)
      141 (31.5)37 (27.0)
      ≥228 (21.5)27 (19.7)
      Extent of dissection.77
      Confined to thoracic aorta25 (19.2)24 (17.5)
      Thoraco-abdominal aorta75 (57.7)85 (62.0)
      Extended to iliac vessels30 (23.1)28 (20.4)
      Blood supply of visceral arteries
      Coeliac artery, TL/FL/TF95 (73.1)/17 (13.1)/18 (13.8)106 (77.4)/13 (9.5)/18 (13.1).62
      Superior mesenteric artery, TL/FL/TF106 (81.5)/7 (5.4)/17 (13.1)121 (88.3)/8 (5.8)/8 (5.8).13
      Left renal artery, TL/FL/TF103 (79.2)/16 (12.3)/11 (8.5)111 (81.0)/21 (15.3)/5 (3.6).22
      Right renal artery, TL/FL/TF94 (72.3)/23 (17.7)/ 13 (10.0)110 (80.3)/16 (11.7)/11 (8.0).29
      Thoracic aorta
      Maximum diameter of aorta – mm39.3 ± 9.740.9 ± 8.2.15
      False lumen status.52
      Patent70 (53.8)69 (50.4)
      Partially thrombosed56 (43.1)60 (43.8)
      Completely thrombosed4 (3.1)8 (5.8)
      Abdominal aorta
      Maximum diameter of aorta – mm30.8 ± 6.731.2 ± 5.6.64
      False lumen status.80
      Patent74 (56.9)73 (53.3)
      Partially thrombosed25 (19.2)32 (23.4)
      Completely thrombosed6 (4.6)8 (5.8)
      Normal25 (19.2)24 (17.5)
      High risk radiographic features
      Aortic diameter >40 mm63 (48.5)80 (58.4).10
      FL diameter >22 mm35 (26.9)50 (36.5).093
      Primary entry tear diameter >10 mm37 (28.5)37 (27.0).79
      Patent thrombosed FL70 (53.8)69 (50.4).57
      Partially thrombosed FL56 (43.1)60 (43.8).91
      ≥1 high risk radiographic feature81 (62.3)90 (65.7).56
      Data are presented as n (%) or mean ± standard deviation. COPD = chronic obstructive pulmonary disease; FL = false lumen; TF = true lumen and false lumen; TL = true lumen.
      Table 2Details of thoracic endovascular aortic repair (TEVAR) intervention and early outcomes in 267 uncomplicated type B aortic dissection (uTBAD) patients
      Acute intervention (n = 130)Subacute intervention (n = 137)p
      Procedure details
       Hospitalisation from admission to TEVAR – d4.6 ± 2.54.9 ± 2.3.20
      Proximal landing zone.73
      Zone 272 (55.4)73 (53.3)
      Zone 358 (44.6)64 (46.7)
      More than one stent graft placed11 (8.5)18 (13.1).22
      Restrictive bare stent12 (9.2)11 (8.0).73
      LCCA-LSA bypasses4 (3.1)10 (7.3).12
      LSA chimney stent graft placed38 (29.2)30 (21.9).17
      Cerebrospinal fluid drainage17 (13.1)23 (16.8).40
      Thoracic aortic stent grafts
       Diameter – mm33.5 ± 3.234.0 ± 2.9.17
       Length – mm194.6 ± 16.0195.5 ± 13.6.64
      Brand.22
      Valiant (Medtronic, MN, USA)47 (36.2)54 (39.4)
      Zenith TX2 (Cook, IN, USA)10 (7.7)13 (9.5)
      cTAG (Gore, AZ, USA)18 (13.8)25 (18.2)
      Ankura (Lifetech, Shenzhen, China)45 (34.6)29 (21.2)
      Hercules-T (Microport, Shanghai, China)5 (3.8)10 (7.3)
      Aortec (YTH, Beijing, China)5 (3.8)6 (4.4)
      Early outcomes at 30 days
       Hospitalisation post-TEVAR – d7.5 ± 4.27.0 ± 4.1.42
       Death5 (3.8)1 (0.7).11
       Aortic rupture2 (1.5)0 (0.0).24
       Retrograde type A dissection1 (0.8)0 (0.0).49
       Immediate type Ia endoleak11 (8.5)10 (7.3).72
       Disabling stroke1 (0.8)0 (0.0).49
       Minor stroke/TIA2 (1.5)1 (0.7).61
       Spinal cord ischaemia1 (0.8)3 (2.2).62
       Re-intervention1 (0.8)1 (0.7)1.0
      Data are presented as mean ± standard deviation or n (%). LCCA = left common carotid artery; LSA = left subclavian artery; TEVAR = thoracic endovascular aortic repair; TIA = transient ischaemic attack.

      Early outcomes

      The primary technique success rate was 92.1% (246/267), with 21 patients showing immediate type Ia endoleaks (ELIa) on completion angiography. Given that the immediate ELIa were low flow, those patients were treated conservatively with close follow up. No significant difference was noted across timing cohorts in early events (Table 2). Of note, 30 day mortality in the acute group was five times higher than that in subacute group (3.8% vs. 0.7%, p = .11), and aortic ruptures, RTAD, and disabling stroke were observed only in the acute group. Multivariable logistic analyses showed that intervention timing was not independently associated with any early outcomes (Table 3).
      Table 3Association of timing (acute intervention vs. subacute intervention) on early and late outcomes after multivariable adjustment
      OR or HR (95% CI)p value
      Early outcomes at 30 days
      The impact of timing (acute vs. subacute) on early outcomes was evaluated by univariable and multivariable logistic regression models.
       All cause death0.22 (0.02–2.06).18
       Immediate type Ia endoleak0.82 (0.33–2.02).67
       Any stroke0.40 (0.04–4.17).44
       Spinal cord ischaemia2.51 (0.19–32.56).48
       Re-intervention0.94 (0.06–15.26).97
      Late outcomes after 30 days
      The impact of timing (acute vs. subacute) on late outcomes was evaluated by univariable and multivariable Cox regression models.
       All cause death1.95 (0.67–5.68).22
       Dissection related death2.74 (0.55–13.62).22
       Re-intervention0.33 (0.06–1.70).18
       Aortic related late events0.70 (0.34–1.47).35
      Covariates included in the model for early and late outcomes: age, sex, hypertension, diabetes mellitus, hyperlipidaemia, cerebrovascular disease, coronary artery disease, chronic obstructive pulmonary disease, chronic kidney disease, current smoker, transfer status, primary entry tear size, re-entry tears, extent of dissection (confined to thoracic aorta as a reference), number of visceral arteries involved, maximum diameter of thoracic aorta, false lumen status of thoracic aorta, maximum diameter of abdominal aorta, and false lumen status of abdominal aorta. Age, sex, and variables with a p value < .1 in univariable analysis were entered in the multivariable models. CI = confidence interval; HR = hazard ratio; OR = odds ratio.
      The impact of timing (acute vs. subacute) on early outcomes was evaluated by univariable and multivariable logistic regression models.
      The impact of timing (acute vs. subacute) on late outcomes was evaluated by univariable and multivariable Cox regression models.
      The 30 day mortality rate was 2.2% (6/267). Two patients who died of aortic rupture were confirmed by point of care ultrasound, with one 53 year old man receiving TEVAR with landing zone 3 on day 3 from symptom onset who died on day 6 post-operatively, while another 61 year old man received TEVAR with landing zone 3 on day 11 from symptom onset and died on day 8 post-operatively. One 54 year old woman received TEVAR with landing zone 3 on day 10 from symptom onset and died of RTAD that could not be fixed by surgery on day 5 post-operatively. The reasons for the remaining deaths were pulmonary infection and subsequent respiratory failure (n = 1), disabling stroke (n = 1), and sudden cardiac arrest (n = 1). There were four strokes, one disabling and three minor. Four patients experienced transient SCI, which recovered after CSF drainage. There were two re-interventions, with one for extension of dissection and one for an access related complication.

      Late outcomes

      The clinical and imaging follow up outcomes are shown in Table 4. The clinical follow up completeness rate was 96.9% (253/261). The median clinical follow up duration was 48.2 ± 25.9 months (range 1 – 106 months). Fifteen deaths were documented, including nine dissection related deaths, with seven resulting from aortic rupture and two from RTAD. Five deaths were considered as non-dissection related deaths (cardiac related, n = 2; cancer related, n = 1; pneumonia, n = 1; cerebral haemorrhage, n = 1). The reasons for the last two deaths could not be determined. The incidence of distal SINE was 1.6% (4/253), while no proximal SINE was detected. Of three patients in the acute group, two were treated by re-TEVAR because of FL growth (14 months and 25 months, respectively) and one was managed medically because there was no change in the FL (44 months). The last distal SINE was in the subacute group, with no requirement for re-intervention until the last follow up (first detected at 18 months; last follow up at 61 months). Moreover, three patients received re-TEVAR because of extension of dissection, one patient received re-TEVAR because of persistent FL perfusion, and the last two patients received an additional treatment to seal the origin of the LSA because of type II endoleak.
      Table 4Clinical follow up outcomes of 253 patients with uncomplicated type B aortic dissection treated by thoracic endovascular aortic repair and follow up computed tomography angiography (CTA) imaging features of 222 patients
      Acute intervention (n = 120)Subacute intervention (n = 133)p value
      Clinical outcomes
       Follow up time – mo46.4 ± 25.649.9 ± 26.1.29
      Death5 (4.2)11 (8.3).18
      Dissection related death3 (2.5)6 (4.5).50
      Non-dissection related death1 (0.8)4 (3.0).37
      Unknown1 (0.8)1 (0.8)1.0
       Aortic rupture2 (1.7)5 (3.8).45
       Retrograde type A dissection1 (0.8)1 (0.8)1.0
       Late type Ia endoleak3 (2.5)1 (0.8).35
       Type Ib endoleak2 (1.7)4 (3.0).69
       Type II endoleak2 (1.7)0 (0.0).22
       Distal stent graft induced new entry tear3 (2.5)1 (0.8).35
       Re-intervention6 (5.0)2 (1.5).16
      Imaging outcomes
      In imaging follow up, total n=222.
       No. of patients107115
       Follow up time – mo39.3 ± 25.142.7 ± 25.8.33
      Original type Ia endoleak
      With original type Ia endoleak, total n=21.
      .82
      Persisted2 (18.2)2 (20.0)
      Disappeared8 (72.7)6 (60.0)
      Lost follow up1 (9.1)2 (20.0)
      Thoracic aorta
      Maximum diameter of aorta – mm36.4 ± 8.637.8 ± 8.0.31
      False lumen status.79
      Partially thrombosed10 (9.3)12 (10.4)
      Completely thrombosed97 (90.7)103 (89.6)
      Abdominal aorta
      Maximum aortic diameter – mm32.7 ± 8.334.1 ± 7.9.19
      False lumen status.61
      Patent22 (20.6)21 (18.3)
      Partially thrombosed35 (32.7)47 (40.9)
      Completely thrombosed30 (28.0)26 (22.6)
      Normal20 (18.7)21 (18.3)
      Data are presented as mean ± standard deviation or n (%).
      In imaging follow up, total n=222.
      With original type Ia endoleak, total n=21.
      In this study, 39 patients were lost to imaging follow up (lost contact, n = 8; economic reasons, n = 6; receiving CTA in other hospitals but could not provide imaging data, n = 20; patient refusal, n = 5). Only 85.1% (222/261) of patients received at least one imaging follow up, and the median imaging follow up duration was 41.1 ± 25.5 months (range 1 – 97 months). Of all the patients, 90.1% (200/222) achieved a completely thrombosed FL in the thoracic aorta, while 30.9% (56/181) did so in the abdominal aorta. Moreover, 80.6% (179/222) of patients experienced a stable or shrinking (> 5 mm) maximum aortic diameter of the thoracic aorta, while 37.0% (67/181) experienced an increase in (> 5 mm) maximum aortic diameter of the abdominal aorta. Both FL status and maximum aortic diameter, either at thoracic aorta level or abdominal aorta level, did not show significant differences between the two groups. Among 21 patients with immediate ELIa, four (19.0%) patients persisted, 14 patients (66.7%) recovered, and three (14.3%) patients were lost to imaging follow up. For the cases with persistent ELIa, re-interventions were not required because of absence of aorta enlargement.
      The cumulative survival rate from all cause death in the acute group at five years was 94.2% (95% confidence intervals [CI] 89.1% – 99.6%) and in the subacute group was 88.3% (95% CI 81.5% – 95.7%), respectively. The cumulative incidence of dissection related death in the acute group at five years was 3.2% (95% CI 3.1% – 3.3%), and in the subacute group was 5.5% (95% CI 5.4% – 5.6%), respectively. The cumulative freedom from aortic related late events in the acute group at five years was 84.5% (95% CI 77.1% – 92.6%), and in the subacute group was 90.6% (95% CI 85.0% – 96.6%), respectively. There was no significant difference in all cause death (Fig. 2A), dissection related death (Fig. 2B), late intervention (Fig. 2C), and aortic related late events (Fig. 3) between the two groups. Multivariable Cox analyses showed that intervention timing was not independently associated with any late outcomes (Table 3).
      Figure 2
      Figure 2Cumulative Kaplan–Meier estimates of freedom from (A) all cause death, (B) late intervention, and (C) aortic related late events, according to acute or subacute timing for thoracic endovascular aortic repair (TEVAR) of uncomplicated type B aortic dissection in 253 patients. The reasons for exclusion from the survival analysis were deaths within 30 days (n = 6) and loss to clinical follow up (n = 8).
      Figure 3
      Figure 3Cumulative incidence of dissection related death with other cause death as a competing risk based on 253 patients with uncomplicated type B aortic dissection treated by thoracic endovascular aortic repair (TEVAR) either acutely or subacutely. The reasons for exclusion from the survival analysis were deaths within 30 days (n = 6) and loss to clinical follow up (n = 8).
      Compared with patients without LSA chimney stent grafts, patients receiving LSA chimney stent grafts experienced a statistically significantly higher rate of immediate ELIa (14.7% vs. 5.5%; p = .015; Table S1). Other early outcomes and late outcomes were similar between patients with and without LSA chimney stent grafts.

      Discussion

      The present study compared the outcomes of patients with uTBAD who received pre-emptive TEVAR in the acute phase with those in the subacute phase. There was no statistically significant difference in early and late outcomes among timing groups. However, the higher early mortality and morbidity rates in the acute phase are a concern.
      Although lacking level 1 evidence, pre-emptive TEVAR is increasingly being performed in patients with uTBAD who are at high risk of late aortic related complications.
      • Erbel R.
      • Aboyans V.
      • Boileau C.
      • Bossone E.
      • Bartolomeo R.D.
      • Eggebrecht H.
      • et al.
      2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC).
      ,
      • Riambau V.
      • Bockler D.
      • Brunkwall J.
      • Cao P.
      • Chiesa R.
      • Coppi G.
      • et al.
      Editor's Choice - Management of Descending Thoracic Aorta Diseases: Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS).
      A recent review summarised some high risk radiological features of uTBAD: an initial FL diameter of ≥ 22 mm, a maximum aortic diameter of ≥ 40 mm at initial presentation, a patent or partially thrombosed FL, and an initial entry tear of ≥ 10 mm.
      • Tadros R.O.
      • Tang G.
      • Barnes H.J.
      • Mousavi I.
      • Kovacic J.C.
      • Faries P.
      • et al.
      Optimal treatment of uncomplicated Type B aortic dissection: JACC Review Topic of the Week.
      In the 2020 reporting standard for TBAD, location of the tear (inner vs. outer aortic curve), bloody pleural effusion, and radiographic only malperfusion were also considered as high risk radiographic features.
      • Lombardi J.V.
      • Hughes G.C.
      • Appoo J.J.
      • Bavaria J.E.
      • Beck A.W.
      • Cambria R.P.
      • et al.
      Society for Vascular Surgery (SVS) and Society of Thoracic Surgeons (STS) reporting standards for type B aortic dissections.
      In addition, Gao and colleagues reported more aggressive management, namely, to offer TEVAR to all patients with uTBAD at their centre.
      • Gao H.Q.
      • Xu S.D.
      • Ren C.W.
      • Yang S.
      • Liu C.L.
      • Zhen J.
      • et al.
      Analysis of perioperative outcome and long term survival rate of thoracic endovascular aortic repair in uncomplicated type B dissection: single-centre experience with 751 patients.
      With the increasing use of TEVAR in uTBAD, the optimal intervention timing needs to be identified.
      Wang and colleagues reviewed 103 patients with uTBAD from the SVS VQI TEVAR surveillance project, and divided them into four groups: ≤ 48 hours, > 48 hours to < 7 days, ≥ 7 days to ≤ 14 days, and > 14 days to < 30 days.
      • Wang G.J.
      • Cambria R.P.
      • Lombardi J.V.
      • Azizzadeh A.
      • White R.A.
      • Abel D.B.
      • et al.
      Thirty-day outcomes from the Society for Vascular Surgery Vascular Quality Initiative thoracic endovascular aortic repair for type B dissection project.
      They failed to show any patterns in 30 day mortality or re-intervention based on timing of treatment. Of note, Wang et al. pointed out that optimal timing remained inconclusive, with the low incidences of re-interventions. Still, long term outcomes including aortic remodelling are lacking to determine the optimal timing of intervention.
      Previous studies have reported that the 30 day mortality rates, RTAD, stroke, and SCI in patients with acute uTBAD
      • Qin Y.L.
      • Wang F.
      • Li T.X.
      • Ding W.
      • Deng G.
      • Xie B.
      • et al.
      Endovascular Repair compared with medical management of patients with uncomplicated Type B acute aortic dissection.
      ,
      • Iannuzzi J.C.
      • Stapleton S.M.
      • Bababekov Y.J.
      • Chang D.
      • Lancaster R.T.
      • Conrad M.F.
      • et al.
      Favorable impact of thoracic endovascular aortic repair on survival of patients with acute uncomplicated type B aortic dissection.
      ,
      • Wang G.J.
      • Cambria R.P.
      • Lombardi J.V.
      • Azizzadeh A.
      • White R.A.
      • Abel D.B.
      • et al.
      Thirty-day outcomes from the Society for Vascular Surgery Vascular Quality Initiative thoracic endovascular aortic repair for type B dissection project.
      ,
      • Xiang D.
      • Kan X.
      • Liang H.
      • Xiong B.
      • Liang B.
      • Wang L.
      • et al.
      Comparison of mid-term outcomes of endovascular repair and medical management in patients with acute uncomplicated type B aortic dissection.
      treated by TEVAR were 0.5% – 7.1%, 0.5% – 1.6%, 0.5% – 6.0%, and 0 – 3.4%, respectively; while in patients with non-acute uTBAD,
      • Wang G.J.
      • Cambria R.P.
      • Lombardi J.V.
      • Azizzadeh A.
      • White R.A.
      • Abel D.B.
      • et al.
      Thirty-day outcomes from the Society for Vascular Surgery Vascular Quality Initiative thoracic endovascular aortic repair for type B dissection project.
      ,
      • Nienaber C.A.
      • Rousseau H.
      • Eggebrecht H.
      • Kische S.
      • Fattori R.
      • Rehders T.C.
      • et al.
      Randomized comparison of strategies for type B aortic dissection: the INvestigation of STEnt Grafts in Aortic Dissection (INSTEAD) trial.
      ,
      • Nienaber C.A.
      • Kische S.
      • Rousseau H.
      • Eggebrecht H.
      • Rehders T.C.
      • Kundt G.
      • et al.
      Endovascular repair of type B aortic dissection: long term results of the randomized investigation of stent grafts in aortic dissection trial.
      they were 0 – 4.5%, 0 – 1.5%, 0 – 1.5%, and 2.9% – 4.5%, respectively. The present results are concordant with these studies, in which the rates of death, RTAD, stroke, and SCI within 30 days post-operatively in the acute group were 3.8%, 0.8%, 2.3%, and 0.8%, while in the subacute group were 0.7%, 0, 0.7%, and 2.2%, respectively. Moreover, the present authors found no significant difference in the 30 day outcome rates between the two groups. These results verified the recent findings of the SVS VQI TEVAR surveillance project, where a low incidence of re-intervention did not allow for detecting any trends. Of note, aortic ruptures, RTAD, and disabling stroke were observed only in the acute group. Among these cases, all primary entry tears were completely covered and the oversizing was 5% – 10%. Such results should undoubtedly raise more attention, which might support previous observations that early intervention increases the risk of peri-operative complications because of the fragile intima of the inflamed aorta.
      • Desai N.D.
      • Gottret J.P.
      • Szeto W.Y.
      • McCarthy F.
      • Moeller P.
      • Menon R.
      • et al.
      Impact of timing on major complications after thoracic endovascular aortic repair for acute type B aortic dissection.
      Survival rates after TEVAR for uTBAD have been reported to range from 75.9% to 91.9% at five years, and aortic related survival rates were 89.0% to 94.1%.
      • Qin Y.L.
      • Wang F.
      • Li T.X.
      • Ding W.
      • Deng G.
      • Xie B.
      • et al.
      Endovascular Repair compared with medical management of patients with uncomplicated Type B acute aortic dissection.
      ,
      • Iannuzzi J.C.
      • Stapleton S.M.
      • Bababekov Y.J.
      • Chang D.
      • Lancaster R.T.
      • Conrad M.F.
      • et al.
      Favorable impact of thoracic endovascular aortic repair on survival of patients with acute uncomplicated type B aortic dissection.
      ,
      • Gao H.Q.
      • Xu S.D.
      • Ren C.W.
      • Yang S.
      • Liu C.L.
      • Zhen J.
      • et al.
      Analysis of perioperative outcome and long term survival rate of thoracic endovascular aortic repair in uncomplicated type B dissection: single-centre experience with 751 patients.
      • Nienaber C.A.
      • Rousseau H.
      • Eggebrecht H.
      • Kische S.
      • Fattori R.
      • Rehders T.C.
      • et al.
      Randomized comparison of strategies for type B aortic dissection: the INvestigation of STEnt Grafts in Aortic Dissection (INSTEAD) trial.
      • Nienaber C.A.
      • Kische S.
      • Rousseau H.
      • Eggebrecht H.
      • Rehders T.C.
      • Kundt G.
      • et al.
      Endovascular repair of type B aortic dissection: long term results of the randomized investigation of stent grafts in aortic dissection trial.
      • Xiang D.
      • Kan X.
      • Liang H.
      • Xiong B.
      • Liang B.
      • Wang L.
      • et al.
      Comparison of mid-term outcomes of endovascular repair and medical management in patients with acute uncomplicated type B aortic dissection.
      In the present study, the cumulative survival rate from all cause death at five years was 90.9% and from dissection related death was 95.5%, with no significant difference between the groups. In addition, the five year re-intervention rate was 4.1% in the present study, concordant with previous studies (4.6% – 6.0%).
      • Qin Y.L.
      • Wang F.
      • Li T.X.
      • Ding W.
      • Deng G.
      • Xie B.
      • et al.
      Endovascular Repair compared with medical management of patients with uncomplicated Type B acute aortic dissection.
      ,
      • Gao H.Q.
      • Xu S.D.
      • Ren C.W.
      • Yang S.
      • Liu C.L.
      • Zhen J.
      • et al.
      Analysis of perioperative outcome and long term survival rate of thoracic endovascular aortic repair in uncomplicated type B dissection: single-centre experience with 751 patients.
      ,
      • Xiang D.
      • Kan X.
      • Liang H.
      • Xiong B.
      • Liang B.
      • Wang L.
      • et al.
      Comparison of mid-term outcomes of endovascular repair and medical management in patients with acute uncomplicated type B aortic dissection.
      These findings are consistent with the results of Desai et al., in which the timing of TEVAR did not make a difference to late outcomes.
      • Desai N.D.
      • Gottret J.P.
      • Szeto W.Y.
      • McCarthy F.
      • Moeller P.
      • Menon R.
      • et al.
      Impact of timing on major complications after thoracic endovascular aortic repair for acute type B aortic dissection.
      Furthermore, the present study found that aortic remodelling, in either the thoracic aorta or abdominal aorta, was similar between the two groups, which validated the findings of the VIRTUE registry.
      Virtue Registry Investigators. Mid-term outcomes and aortic remodelling after thoracic endovascular repair for acute, subacute, and chronic aortic dissection: the VIRTUE Registry.
      In this study, 68 (25.5%) patients received LSA chimney stent grafts. The chimney technique is supposed to have higher rates of complications as greater oversizing is required. However, the present results showed that patients receiving LSA chimney stent grafts experienced a significantly higher rate of immediate ELIa but similar rates of other early and late outcomes (Table S1). As the gutters go alongside the aortic stent graft, chimney stent graft, and thoracic aortic wall, the chimney technique will undoubtedly increase the risk of ELIa. Previous studies by the present authors demonstrated that immediate ELIa resulting from the chimney technique did not increase mid-term all cause death, aorta related death, major adverse events, or chimney stent occlusion.
      • Sayer D.
      • Bratby M.
      • Brooks M.
      • Loftus I.
      • Morgan R.
      • Thompson M.
      Aortic morphology following endovascular repair of acute and chronic type B aortic dissection: implications for management.
      After excluding the patients having LSA revascularisation, there were still no significant differences in early and late outcomes between the two groups; and 30 day death in the acute group was four times higher than in the subacute group (4.5% vs. 1.0%; p = .19; Table S2). Apart from the revascularisation of supra-aortic branches, the assessment of aortic tortuosity and angulations was also critical, as it may be more facilitating in case of arch I and II and more complex in arch III.
      • Saremi F.
      • Hassani C.
      • Lin L.M.
      • Lee C.
      • Wilcox A.G.
      • Fleischman F.
      • et al.
      Image Predictors of Treatment Outcome after Thoracic Aortic Dissection Repair.
      The present study may provide useful insights for TEVAR based management of patients with uTBAD. However, as this study is a negative study, the risk of type II error should be considered. These results must be interpreted carefully. Although without statistically significant difference, higher rates of early events in the acute group, including death, aortic rupture and RTAD, require attention. The follow up period was relatively short, and the effect of intervention timing on long term outcomes and aortic remodelling needs further studies to confirm. Furthermore, patients in the present study represented a subset of patients at high risk of late aortic related complications, while not all patients with uTBAD benefited from pre-emptive TEVAR.
      The present study has several limitations. First, the patient grouping was not randomised, and potential selection bias could not be completely avoided. Second, the indications for TEVAR for uTBAD remain under debate. Furthermore, this was a retrospective analysis across a period of eight years, which leads to heterogeneity in various aspects. Follow up was not performed in one but in multiple centres. More robust data provided by randomised trials will be necessary to answer more definitively the questions of how and when to best treat acute uTBAD.
      In conclusion, the present study has indicated that pre-emptive TEVAR for high risk uTBAD in acute phase is associated with a trend toward higher rates of early events, while the long term outcomes including aortic remodelling were comparable with those in the subacute phase. Further randomised controlled trials are needed to examine the optimal timing of TEVAR for uTBAD.

      Acknowledgements

      The authors wish to acknowledge Dr. Huimin Cai, from Shantou University Medical College, for language help.

      Conflict of interest

      None.

      Funding

      This work was supported by the High-level Hospital Construction Project [grant number DFJH201807 ]; and Science and Technology Planning Project of Guangdong Province [grant number 2017B030314041 ].

      Appendix A. Supplementary data

      Figure S1
      Figure S1The annual number of TEVARs for uTBAD between acute and subacute groups. There was no significant difference of annual number between the two groups (p = .70). TEVAR = thoracic endovascular aortic repair; uTBAD = uncomplicated type B aortic dissection.

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      Linked Article

      • TEVAR for Uncomplicated Type B Aortic Dissection: A Hasty Strike May Further Complicate the Knot
        European Journal of Vascular and Endovascular SurgeryVol. 61Issue 5
        • Preview
          In this issue Luo and colleagues present a retrospective single centre study of 267 patients with uncomplicated type B aortic dissection (uTBAD), treated by TEVAR in the acute (130) or subacute (137) phase.1 All patients had risk factors for complications/progression. There was no statistically significant difference in early/late outcomes between the groups. However, on a descriptive basis, the 30 day mortality rate after pre-emptive TEVAR was five times higher for treatment in the acute phase (3.8%) than in the subacute phase (0.7%; p = .11).
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