Incidence of mortality and surgical reintervention following thoracic endovascular aortic repair for uncomplicated type B aortic dissection

Background Uncomplicated type B aortic dissection (uTBAD) is primarily managed through optimal medical therapy, whereas complicated cases typically require thoracic endovascular aortic repair (TEVAR). There are published data that suggest that patients managed long-term with optimal medical therapy have an increased likelihood of requiring crossover TEVAR in the emergent acute setting, which are generally associated with poorer outcomes when compared with the nonacute setting. These findings raise consideration for whether TEVAR may be used for patient populations that remain asymptomatic to prevent these delayed acute encounters. This systematic review aims to evaluate mortality, surgical reintervention, and adverse outcomes after TEVAR in patients with uTBAD, stratified by timing of intervention. Methods In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we searched MEDLINE and Embase for studies on TEVAR outcome data for uTBAD published between 2014 and 2024. Eligible studies reported 30-day or 1-year incidence of mortality, surgical reintervention, and/or adverse events after TEVAR, with data stratified by intervention timing. Risk of bias was assessed using the Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I) tool, and evidence quality was evaluated using a modified Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. Results Eleven studies from a screen of 2308 were included, comprising retrospective cohort analyses of 70 to 1536 patients. Acute-phase TEVAR demonstrated 30-day mortality rates ranging from 0.5% to 7.5%, compared with 0.0% to 2.7% in the subacute phase and 1.6% to 2.4% in the chronic phase. One-year mortality ranged from 4.7% to 15.7% in acute interventions and up to 8.2% in subacute interventions, with no data for chronic cases. Reintervention rates were higher in acute-phase TEVAR, ranging from 0.8% to 11.4%, compared with 0.7% to 6.8% in the subacute phase. Adverse outcomes, including endoleak, stroke, and retrograde type A aortic dissection, were more frequent in acute-phase interventions. Conclusions Subacute-phase TEVAR appears to offer optimal outcomes in patients with uTBAD, balancing the risks of acute hemodynamic instability and challenges of chronic anatomical changes. Although emerging evidence supports earlier intervention, high-quality contemporary studies are needed to refine patient selection and intervention timing. Furthermore, there are limited consistent end points for long-term outcome data, which is necessary to improve on treatment guidelines.