title: Aortic arch involvement worsens the prognosis of type B aortic dissections.
abstract: OBJECTIVE
  Medical management of acute aortic dissections limited to the descending thoracic aorta (AD-desc) is associated with acceptable outcomes. Uncertainty remains about whether acute type B aortic dissections involving the aortic arch (AD-arch) have an increased risk of retrograde extension into the ascending aorta or other dissection-related complications. This study compared outcomes of AD-arch with AD-desc managed medically.
  
  
  METHODS
  Consecutive patients admitted from 2005 to 2014 with acute aortic dissections not involving the ascending aorta were retrospectively analyzed. Primary end points included dissection-related death and operative intervention.
  
  
  RESULTS
  The study included 99 patients (63% men; mean age, 60 ± 14 years) with acute aortic dissections. Dissections were limited to the aorta distal to the left subclavian artery (AD-desc) in 79 patients (80%), and 20 (20%) had involvement of the left subclavian (n = 16), left common carotid (n = 1), or innominate (n = 3) arteries (AD-arch). Dissections ended proximal to the celiac artery in 30 patients (30%), between the celiac artery and aortic bifurcation in 36 (36%), and distal to the aortic bifurcation in 33 (33%). During medical management, further proximal extension into the arch occurred in two AD-arch patients and one AD-desc patient (P < .05), but proximal dissection into the ascending aorta occurred in only one AD-arch patient with Marfan disease. Compared with patients with AD-desc, those with AD-arch were younger (53 ± 12.5 vs 62 ± 16 years; P < .01) and had more frequent early interventions (40% vs 19%; P = .047), cardiac complications (35% vs 11%; P < .01), and neurologic events (25% vs 6%; P < .01). Seven AD-arch patients (35%) and nine AD-desc patients (11%) died of dissection-related causes (P < .01). Among survivors, late interventions were performed in four of eight AD-arch patients (50%) and in six of 58 AD-desc patients (10%; P = .02). Medical treatment without intervention was successful in four AD-arch patients (20%) and in 52 AD-desc patients (66%; P < .001). Multivariate logistic regression retained arch involvement as the sole predictor of dissection-related death (odds ratio, 4.2; 95% confidence interval, 1.3-13.4) and failure of medical treatment (odds ratio, 7.7; 95% confidence interval, 2.5-29). The distal extent of dissection had no bearing on outcome.
  
  
  CONCLUSIONS
  AD-arch dissections are associated with a higher risk of cardiac and neurologic events, need for early intervention, and dissection-related death than AD-desc dissections. Because further proximal dissections into the ascending aorta were rare in this study, medical management appears to be safe as the initial treatment of AD-arch dissections. However, surgeons should be aware of the increased risk of complications and the potential need for urgent interventions in these patients.
authors.affiliation: Department of Surgery, Vanderbilt University Medical Center, Nashville, Tenn. Electronic address: james.valentine@vanderbilt.edu.
authors.forename: R James
authors.initials: RJ
authors.lastname: Valentine
authors.affiliation: Department of Surgery, Vanderbilt University Medical Center, Nashville, Tenn.
authors.forename: Julia M
authors.initials: JM
authors.lastname: Boll
authors.affiliation: Department of Biomedical Engineering, Vanderbilt University, Nashville, Tenn.
authors.forename: Kyle M
authors.initials: KM
authors.lastname: Hocking
authors.affiliation: Department of Surgery, Vanderbilt University Medical Center, Nashville, Tenn.
authors.forename: John A
authors.initials: JA
authors.lastname: Curci
authors.affiliation: Department of Surgery, Vanderbilt University Medical Center, Nashville, Tenn.
authors.forename: C Louis
authors.initials: CL
authors.lastname: Garrard
authors.affiliation: Division of Vascular Surgery, Department of Surgery, VA Tennessee Valley Healthcare System, Nashville, Tenn.
authors.forename: Colleen M
authors.initials: CM
authors.lastname: Brophy
authors.affiliation: Department of Surgery, Vanderbilt University Medical Center, Nashville, Tenn.
authors.forename: Thomas C
authors.initials: TC
authors.lastname: Naslund
mesh_terms: D000208:Acute Disease; D000328:Adult; D000368:Aged; D000784:Aortic Dissection / Q000150:complications / Q000000981:diagnostic imaging / Q000401:mortality / Q000628:therapy*; D001013:Aorta, Thoracic / Q000000981:diagnostic imaging / Q000601:surgery; D017545:Aortic Aneurysm, Thoracic / Q000150:complications / Q000000981:diagnostic imaging / Q000401:mortality / Q000628:therapy*; D001027:Aortography / Q000379:methods; D002317:Cardiovascular Agents / Q000009:adverse effects / Q000627:therapeutic use*; D016009:Chi-Square Distribution; D018450:Disease Progression; D005260:Female; D006331:Heart Diseases / Q000209:etiology; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009422:Nervous System Diseases / Q000209:etiology; D016017:Odds Ratio; D012189:Retrospective Studies; D012307:Risk Factors; D013714:Tennessee; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures
chemical_list: D002317:Cardiovascular Agents