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OBJECTIVE: To evaluate the relationship between operative mortality and increasing patient age or comorbidity burden in open versus endovascular repair of Stanford type B aortic dissections (TBAD).
METHODS: Patients undergoing open or endovascular repair of thoracic or thoracoabdominal TBAD between 2005-2008 were identified in the Nationwide Inpatient Sample. Patients with aortic aneurysms or with procedure codes for cardioplegia, or operations on coronary vessels or valves were excluded from analysis. The primary outcome was operative mortality. The relationships between operative mortality and increasing patient age or Charlson comorbidity index were compared between approaches.
RESULTS: A total of 8,202 patients underwent TBAD repair, with 1,522(18.6%) being endovascular. The overall operative mortality rate was 16.6%. In both elective and urgent/emergent cases, an endovascular approach was associated with reduced operative mortality compared to open repair (elective: 1.1% versus 10.2%, p=0.01; urgent/emergent: 10.0% versus 21.1%, p=0.006). In elective cases, there was a strong association between increasing patient age and increasing operative mortality with open repair (p=0.008) (Figure 1). There was no such association with elective endovascular cases (p=0.68). Similarly, in urgent/emergent cases, the risk of operative mortality increased significantly with increasing age in open (p<0.001), but not endovascular cases (p=0.89). The same relationships were observed with Charlson index, where an increasing comorbidity burden was associated with a significantly increased risk of operative mortality in elective open cases (p=0.004) and a strong trend towards increased mortality in urgent/emergent open cases (p=0.06) (Figure 2). The endovascular approach was associated with similar mortality despite increasing comorbidity burden (elective: p=0.49; urgent/emergent: p=0.99).
CONCLUSIONS: This large-cohort analysis demonstrates that an endovascular, but not an open approach, to TBAD mitigates the adverse impact of increasing age or comorbidity burden on operative mortality risk. These data strongly support the use of endovascular TBAD repair in older patients and/or those with significant comorbidities.