title: Outcomes after stent graft therapy for dissection-related aneurysmal degeneration in the descending thoracic aorta.
abstract: OBJECTIVE
  Stent graft therapy has emerged as an alternative to open surgery in the management of chronic dissection-related aneurysmal degeneration (DRAD) in the descending thoracic aorta (DTA). The incidence of perioperative complications, need for secondary aortic intervention (SAI), and rate of aneurysmal false-lumen thrombosis have not been thoroughly described.
  
  
  METHODS
  Perioperative and midterm outcomes in patients who underwent stent graft therapy for chronic DRAD DTA at a single institution between January 2006 and September 2013 were retrospectively analyzed. Preoperative anatomic factors, including the number of visceral and renal side branches off the false lumen, and false lumen volume, were analyzed for their ability to predict treatment failure. Treatment failure was defined as death, need for a SAI, and failure to achieve thrombosis of the DRAD DTA. Treatment success was defined as thrombosis of the false lumen in the area of the DRAD DTA with stability or a decrease in the maximum diameter of the DRAD DTA.
  
  
  RESULTS
  During the study period, 47 patients underwent stent graft therapy for chronic DRAD DTA. Patients were a mean age of 58.3 ± 11.7 years, 74.5% (n = 35) were male, and 14.9% (n = 7) had a history of connective tissue disease. The left subclavian artery was covered in 48.9% (n = 23), and revascularization was performed in 87.0% (n = 20). Spinal drains were used in 74.5% (n = 35). Spinal cord ischemia developed in 6.4% (n = 3), which resolved in two and improved in one. No retrograde aortic dissections occurred. The 30-day mortality was 4.3% (n = 2); one death was in a patient with rupture. Mean clinical follow-up was 35.1 ± 20.9 months. The 5-year Kaplan-Meier survival was 89% ± 5%. Treatment failure occurred in 18 patients (38.3%): 9 required SAIs, 6 did not have thrombosis of the false lumen in the area of the DRAD DTA, and 4 died, with 1 patient dying during a SAI. No preoperative anatomic factor predicted treatment failure. The 5-year freedom from treatment failure was 54% ± 9%. Including the nine patients who underwent SAI, treatment success was achieved in 85.2% of patients.
  
  
  CONCLUSIONS
  In this single-center experience of stent graft therapy for chronic DRAD DTA, treatment success was achieved in 85% of patients after a SAI rate of 20%. No preoperative anatomic factor predicted treatment failure, which occurred in almost 40% of the patients. Identifying predictors of treatment failure may improve future outcomes.
authors.affiliation: Division of Vascular Surgery, University of Washington, Seattle, Wash.
authors.forename: Derek P
authors.initials: DP
authors.lastname: Nathan
authors.affiliation: Division of Vascular Surgery, University of Washington, Seattle, Wash.
authors.forename: Sherene
authors.initials: S
authors.lastname: Shalhub
authors.affiliation: Division of Vascular Surgery, University of Washington, Seattle, Wash.
authors.forename: Gale L
authors.initials: GL
authors.lastname: Tang
authors.affiliation: Division of Vascular Surgery, University of Washington, Seattle, Wash.
authors.forename: Matthew P
authors.initials: MP
authors.lastname: Sweet
authors.affiliation: Division of Cardiac Surgery, University of Washington, Seattle, Wash.
authors.forename: Edward D
authors.initials: ED
authors.lastname: Verrier
authors.affiliation: Division of Vascular Surgery, University of Washington, Seattle, Wash.
authors.forename: Nam T
authors.initials: NT
authors.lastname: Tran
authors.affiliation: Division of Cardiac Surgery, University of Washington, Seattle, Wash.
authors.forename: Gabriel S
authors.initials: GS
authors.lastname: Aldea
authors.affiliation: Division of Vascular Surgery, University of Washington, Seattle, Wash. Electronic address: starnes@uw.edu.
authors.forename: Benjamin W
authors.initials: BW
authors.lastname: Starnes
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000784:Aortic Dissection / Q000401:mortality / Q000473:pathology / Q000628:therapy*; D001013:Aorta, Thoracic / Q000473:pathology / Q000601:surgery; D017545:Aortic Aneurysm, Thoracic / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation; D015331:Cohort Studies; D018450:Disease Progression; D057510:Endovascular Procedures; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D012042:Registries; D012189:Retrospective Studies; D015607:Stents; D015996:Survival Rate; D016896:Treatment Outcome