What is the best treatment for patients with acute type B aortic dissections--medical, surgical, or endovascular stent-grafting?
BACKGROUND
Controversy continues regarding treatment for patients with acute type B aortic dissection.


METHODS
One hundred eighty-nine patients with acute type B aortic dissection managed over a 36-year period were analyzed retrospectively for three outcome endpoints: survival; freedom from reoperation, and freedom from late aortic-related complications or late death. Risk factors for death were identified using a multivariable Cox proportional hazards model. Then to account for patient selection bias, heterogeneity of the population, and continuous evolution in techniques, propensity score analysis was used to identify risk-matched cohorts (quintiles I and II) in which the results of medical (n = 111) or surgical (n = 31) therapy were compared more comprehensively.


RESULTS
The two main determinants of death were shock (hazard ratio [HR] = 14.5, 95% confidence level [CL] 4.7, 44.5; p < 0.001) and visceral ischemia (HR = 10.9, 95% CL 3.9, 30.3; p < 0.001). Arch involvement, rupture, stroke, previous sternotomy, and coronary or lung disease roughly doubled the hazard. Female sex was also a significant but weaker independent predictor of death. Actuarial survival estimates for all patients were 71%, 60%, 35%, and 17% at 1, 5, 10, and 15 years, respectively, and were similar for the medical and surgical patients. The Marfan syndrome predicted reoperation and late aortic complications or late death. In a separate analysis of the 142 patients in quintiles I and II, survival, freedom from reoperation, as well as freedom from late aortic complications or death were almost identical in the medical and surgical subsets.


CONCLUSIONS
The poor long-term prognosis of patients with acute type B aortic dissection is determined primarily by dissection-related and patient-specific risk factors, which are not readily modifiable. Whether the outlook in the future will be improved using stent-grafts remains to be determined.
Umaña
Juan P
JP
Department of Cardiovascular and Thoracic Surgery, Falk Cardiovascular Research Center, Stanford University School of Medicine, California 94305-5247, USA.
Miller
D Craig
DC
Mitchell
R Scott
RS
D000208:Acute Disease; D000328:Adult; D000368:Aged; D000784:Aortic Dissection / Q000401:mortality / Q000601:surgery*; D000800:Angioplasty, Balloon; D017544:Aortic Aneurysm, Abdominal / Q000401:mortality / Q000601:surgery*; D017545:Aortic Aneurysm, Thoracic / Q000401:mortality / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation; D002423:Cause of Death; D018572:Disease-Free Survival; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008382:Marfan Syndrome / Q000401:mortality / Q000601:surgery; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care; D011183:Postoperative Complications / Q000401:mortality; D016016:Proportional Hazards Models; D012086:Reoperation / Q000401:mortality; D018570:Risk Assessment; D015607:Stents; D015996:Survival Rate