title: Current Experience With Acute Type B Aortic Dissection: Validity of the Complication-Specific Approach in the Present Era.
abstract: BACKGROUND
  Our group proposed in 1992 a "complication-specific approach" for the management of acute aortic dissection type B (TBAD), with uncomplicated cases being treated with medical therapy. In this study, we evaluate the efficacy of this management in in-hospital and postdischarge survival.
  
  
  METHODS
  Between 1999 and 2014, 123 consecutive acute TBAD patients were treated at our institution. We compared complicated (rupture/impending rupture, malperfusion, expansion) vs uncomplicated TBAD, as well as TBAD with a dissection flap vs intramural hematoma/penetrating aortic ulcer.
  
  
  RESULTS
  A total of 103 patients (84%) were strictly managed according to the complication-specific approach, with 93% in-hospital survival. Twenty deviated from complication-specific approach management (triaged to operation by complication-specific approach, but inoperable for a variety of reasons). Independent risk factors for a complicated course in the dissection flap subgroup (n = 89) were history of coronary artery disease (odds ratio. 3.139; p = 0.04) and maximum aortic diameter exceeding 5 cm (odds ratio, 4.586; p = 0.005). Uncomplicated patients were treated medically with antiimpulse therapy. Among the 103 patients treated with the complication-specific approach, long-term survival was 83%, 78%, 71% and 47% at 1, 3, 5, and 10 years, respectively. Between the uncomplicated and complicated groups, 8-year survival was 55% and 49%, respectively (log-rank p = 0.03). Uncomplicated patients showed comparable 6-year survival (log-rank p = 0.06) to matched normal population controls.
  
  
  CONCLUSIONS
  Patients managed with the complication-specific approach showed an overall satisfactory long-term survival over 10 years. No in-hospital deaths occurred in patients with uncomplicated, medically treated acute TBAD, with comparable long-term survival to a matched normal population. These good long-term results provide counterbalancing perspective when considering routine thoracic endovascular aortic repair for all TBAD patients.
authors.affiliation: Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut.
authors.forename: Paris
authors.initials: P
authors.lastname: Charilaou
authors.affiliation: Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut; Department of Surgical Diseases # 2, Kazan State Medical University, Kazan, Russia.
authors.forename: Bulat A
authors.initials: BA
authors.lastname: Ziganshin
authors.affiliation: Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut.
authors.forename: Sven
authors.initials: S
authors.lastname: Peterss
authors.affiliation: Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut; Department of Cardiovascular Surgery, Shahid Gangalal National Heart Center, Bansbari, Kathmandu, Nepal.
authors.forename: Bijoy G
authors.initials: BG
authors.lastname: Rajbanshi
authors.affiliation: Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut.
authors.forename: Cha
authors.initials: C
authors.lastname: Rajakaruna
authors.affiliation: Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut; College of Medicine, Alfaisal University, Riyadh, Saudi Arabia.
authors.forename: Khaled J
authors.initials: KJ
authors.lastname: Zaza
authors.affiliation: Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut; College of Medicine, Alfaisal University, Riyadh, Saudi Arabia.
authors.forename: Mohammad N
authors.initials: MN
authors.lastname: Salloum
authors.affiliation: Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut.
authors.forename: Alexander
authors.initials: A
authors.lastname: Mukherjee
authors.affiliation: Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut.
authors.forename: Maryann
authors.initials: M
authors.lastname: Tranquilli
authors.affiliation: Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut; Department of Economics and Department of Preventive Medicine, Stony Brook University, Stony Brook, New York.
authors.forename: John A
authors.initials: JA
authors.lastname: Rizzo
authors.affiliation: Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut. Electronic address: john.elefteriades@yale.edu.
authors.forename: John A
authors.initials: JA
authors.lastname: Elefteriades
mesh_terms: D000368:Aged; D000784:Aortic Dissection / Q000401:mortality / Q000601:surgery*; D017545:Aortic Aneurysm, Thoracic / Q000401:mortality / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects* / Q000379:methods; D057510:Endovascular Procedures / Q000009:adverse effects*; D005260:Female; D005544:Forecasting; D014943:Global Health; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D011183:Postoperative Complications / Q000453:epidemiology*; D012189:Retrospective Studies; D015996:Survival Rate / Q000639:trends; D013997:Time Factors; D016896:Treatment Outcome