title: Optimal treatment for patients with chronic Stanford type B aortic dissection: endovascularly, surgically or both?
abstract: OBJECTIVE
  Patients with chronic Stanford type B aortic dissections (TBAD) are traditionally treated medically, but some of the affected thoracic and thoracoabdominal aortic segments progress to large aneurysms with a significant risk of rupture. The purpose of this study is to retrospectively evaluate, with an 'all-comers' approach, the survival and the outcome of patients following thoracic endovascular aortic repair (TEVAR) or conventional open surgery for chronic TBAD as a first-line therapy or a secondary option after failed medical treatment.
  
  
  METHODS
  Between January 2000 and May 2010, 80 consecutive patients (59 males, median age 63, inter-quartile range (IQR) 55-69) suffering from chronic TBAD were treated at our institution. Thirty-three were treated medically (Group A, median age: 65, IQR: 58.5-71.5), 32 received TEVAR (Group B, median age: 62, IQR: 54-67.5) and 15 patients underwent conventional open surgery (Group C, median age: 61, IQR: 54-66). The median follow-up was 42 months (range: 0.1-124.7) and 100% complete.
  
  
  RESULTS
  There were no significant differences with regard to age, gender and associated comorbidities between the treatment groups. The overall hospital mortality for chronic TBAD was 6.3% (n = 5); in-hospital mortalities for Groups A, B and C were 3.0, 6.2 and 13.4%, respectively. The incidence of major complications, such as paraplegia, malperfusion, renal failure and cardiac arrhythmia, did not significantly differ between the three groups. Postoperative stroke occurred more often after conventional open surgery (Group C: 13.3%; P = 0.07). Reintervention for TBAD pathology was required in Groups A, B and C in 12.1, 28.1 and 0%, respectively (P = 0.03). Secondary open surgery post-TEVAR was required in 7 cases (21.8%) with no postoperative paraplegia.
  
  
  CONCLUSIONS
  Open surgery for extensive thoracic and thoracoabdominal repair in chronic TBAD may be performed with acceptable early and mid-term outcomes. TEVAR for aortic complications in patients with chronic dissection may be successfully performed as a first-stage procedure in order to stabilize the patient and serve as a 'bridge' to secondary open surgery. However, close surveillance is mandatory for the timely detection of aneurysm enlargement, malperfusion or impending rupture after TEVAR.
authors.affiliation: Department of Cardiac Surgery, Heart Center Leipzig, University of Leipzig, Leipzig, Germany.
authors.forename: Michal
authors.initials: M
authors.lastname: Nozdrzykowski
authors.forename: Christian D
authors.initials: CD
authors.lastname: Etz
authors.forename: Maximilian
authors.initials: M
authors.lastname: Luehr
authors.forename: Jens
authors.initials: J
authors.lastname: Garbade
authors.forename: Martin
authors.initials: M
authors.lastname: Misfeld
authors.forename: Michael A
authors.initials: MA
authors.lastname: Borger
authors.forename: Friedrich-Wilhelm
authors.initials: FW
authors.lastname: Mohr
mesh_terms: D000368:Aged; D000784:Aortic Dissection / Q000601:surgery*; D001014:Aortic Aneurysm / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000379:methods; D057510:Endovascular Procedures / Q000009:adverse effects / Q000379:methods*; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000209:etiology; D016896:Treatment Outcome
keywords: Aortic surgery; Chronic type B aortic dissection (complicated, uncomplicated); Descending aorta; Thoracic endovascular aortic repair; Throacoabdominal aorta