Aortic remodeling and mid-term outcomes in acute type B aortic dissection managed with thoracic endovascular repair or optimal medical therapy

Objective To evaluate aortic remodeling and mid-term clinical outcomes in patients with acute type B aortic dissection (TBAD) according to initial management strategy. Methods This retrospective single-center cohort study included consecutive patients with acute TBAD (symptom duration ≤14 days) treated between 2003 and 2021. Patients were grouped by management strategy (optimal medical therapy [OMT], n=47; thoracic endovascular aortic repair [TEVAR] plus OMT, n=14). Computed tomography angiography was used to measure aortic diameters at four predefined anatomical levels. Primary endpoints were whole-aorta remodeling and segmental (proximal descending thoracic) remodeling on the last follow-up computed tomography. Secondary endpoints were all-cause mortality, any aortic reintervention, and freedom from first reintervention. Predictors of remodeling were assessed using multivariable logistic regression, and survival analyses were performed using Kaplan-Meier methods. No formal sample size calculation was performed owing to the retrospective design; regression models were adjusted for prespecified covariates. Results Whole-aorta remodeling occurred in 9 of 61 patients (15%) (TEVAR 6/14 [43%] vs OMT 3/47 [6%]), and segmental remodeling in 19 of 61 (31%) (TEVAR 11/14 [79%] vs OMT 8/47 [17%]). Initial TEVAR showed an independent association with whole-aorta remodeling (odds ratio [OR], 9.92; 95% confidence interval [CI], 1.91-51.55; P = .006) and segmental remodeling (OR, 31.92; 95% CI, 4.99-204.09; P < .001). A false lumen diameter >20 mm was associated with reduced odds of segmental remodeling (OR, 0.20; 95% CI, 0.04-0.92; P = .038). During follow-up, five of 61 patients (8%) died, and 33 of 61 (54%) underwent at least one aortic reintervention. In unadjusted analyses, overall survival and freedom from first reintervention did not differ significantly between initial management groups (log-rank P = .41 and P = .43). Conclusions In this real-world cohort of acute TBAD, primary TEVAR performed for acute complicated presentations was associated with more favorable aortic remodeling, particularly within the treated thoracic segment. Because treatment allocation was indication-driven, comparisons of survival and freedom from reintervention between groups are descriptive only. The high rate of subsequent aortic procedures underscores the need for lifelong imaging surveillance and often staged repair.