Study: TEVAR 'Acceptable' for Ascending Aortic Dissections

For patients with type A aortic dissections ineligible for open repair, thoracic endovascular aortic repair (TEVAR) was associated with "acceptable" mid-term outcomes, according to a group in China.

Among 15 patients treated at an average of 25.5 days after aortic dissection onset, the endovascular procedure was successful in all cases with no deaths or major morbidities in the perioperative period.

At 12 months, there were substantial enlargements of true lumens and shrinking of false lumens and overall thoracic aorta, Zaiping Jing, MD, PhD, of Changhai Hospital in China, and colleagues reported online in the Journal of the American College of Cardiology.

Over a median of 72 months' follow-up, there were no deaths, but eight complications and four reinterventions, they noted. Additionally, stent grafting had a minimal impact on aortic valve function.

"As the first report to provide details of long-term outcomes following thoracic endovascular aortic repair treatment of patients with type A dissection, [the investigators] have succeeded in moving the discussion beyond the novelty level of 'look, it can be done' to the next developmental stage, poised on the threshold of a prospective clinical trial," according to Michael D. Dake, MD, of California's Stanford University.

"Initially applied to descending thoracic aortic aneurysms, TEVAR is now approved for the treatment of patients with type B aortic dissection and traumatic aortic injury. Recently, ongoing clinical trials of branched grafts that expand the application of TEVAR to the aortic arch and thoraco-abdominal segment are extending the scope of endovascular therapy to previously unapproachable thoracic zones," Dake wrote in an accompanying editorial.

"Now, only one uncharted thoracic territory remains -- the ascending aorta, and with it the potential to touch one of the holy grails of endovascular therapy -- type A dissection."

Jing's group acknowledged that their experience may have been biased. "All these patients were those who survived the initial phase with medicine alone, indicating the selection bias in the study. Meanwhile, the rate of acute ascending aortic dissection was rather low, with seven chronic dissections in 15 patients, which showed an inherent survival bias."

The editorialist agreed, emphasizing that "it is important to understand the details of the selection process in order to properly interpret the long-term outcomes."

"The 15 patients detailed represent only a small fraction of the 181 patients with type A dissection evaluated at their facility during the study period. One hundred forty-two went directly to open surgical repair. The remaining 41 were judged 'unfit' for surgery by a panel of physicians due to multiple high-risk factors defined in the report. These 41 underwent further evaluation during which 15 patients were selected for TEVAR. The remaining 26 were managed medically."

One procedure was performed within a week of dissection onset; seven each were performed in patients whose aortic dissections started 8 to 30 days and more than 30 days ago.

"Additional evidence and studies with larger sample size and longer follow-up are needed to support the durability of this new technique," the authors wrote.