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Background: Chronic complicated Stanford type B dissection is associated with significant mortality and morbidity. We reviewed our experience with surgery for complicated type B dissection to determine surgical outcomes in the era of thoracic endovascular aortic repair (TEVAR).
Methods: From January 2000 to May 2010, 90 patients with chronic type B dissection were evaluated at our institution. Of there, 22 patients (14 male, mean age 61.2±8.2 years) underwent surgical repair. Five patients (23%) had previous aortic surgery (4 after previous ascending/root surgery; one after aortic coarctation repair). Indications for surgery were diameter increase to 59±4mm (n=12), covered rupture (n=1), free rupture (n=2) and failed or complicated TEVAR (n=7; after a median interval of 15 months, range: 4.5-54).
Results: Hospital mortality was 13.5% (one after previous TEVAR, two after primary surgical repair). Neurologic complications occurred in five patients: three patients developed strokes (two after prior TEVAR), one immediate paraplegia (after primary surgery) and one patient monoplegia (after primary surgery). Two patients required permanent haemodialysis (one after previous TEVAR). Seven patients required tracheotomy for respiratory failure. One-year survival was 88%. At a median follow-up of 16 months (range: 2.5-77), sixteen patients (84%) were alive and had required no aortic reintervention.
Conclusions: Open surgical repair remains the benchmark for patients with chronic complicated type B dissection in term of mortality, morbidity and survival. Surgery for complicated TEVAR can be carried out with acceptable outcome.

Table 1. Preoperative Baseline Characteristics of 22 Patients Operated on for Chronic Type B Aortic

	Conservative (n = 15)	Conservative (n = 15)	P value
Age - years	62 (54 - 69)	61 (53 - 66)	0.490
Female sex	5 (33.3%)	3 (42.9%)	1.000
CHD	2 (13.3%)	2 (28.6%)	0.565
Marfan´s Syndrome	2 (13.3%)	0	1.000
COPD	2 (13.3%)	3 (42.9%)	0.274
Renal insufficiency	4 (26.7%)	3 (42.9%)	0.630
Previous neurologic dysfunction Preoperative paraplegia Stroke	0 2 (13.3%)	2 (28.6%) 0	0.091 1.000
Urgent/emergent operation	3 (20.0%)	2 (28.6%)	1.000
Obesity	6 (40.0%)	7 (100%)	0.017

Table 2 Mortality after a median follow-up of 16 months (range: 2.5-77)

Mortality	Conservative (n=15)	Prior TEVAR (n=7)	P value
Hospital	13.3 % (2)	14.3% (1)
1-year	20.0 % (3)	14.3% (1)
3- years	26.7 % (4)	14.3% (1)	0.482

Table 3 Postoperative Details and Complications

	Conservative (n = 15)	Prior TEVAR (n = 7)	P value
Neurological complications - Paraplegia early - Paraplegia late - Stroke	1 (6.7%) 1 (6.7%) 2 (13.3%)	0 0 2 (28.6%)	0.565
Renal insufficiency - Creatinin > 1.5 mg/dl - Temporary HD - Permanent HD	5 (33.3%) 2 (13.3%) 1 (6.7%)	5 (71.4%) 3 (42.9%) 1 (14.3%)	0.172 0.274 1.000
Respiratory complications - Tracheostomy	5 (33.3%)	2 (28.6%)	1.000
Cardiac complications - Cardiac arrest - Pacemaker	1 (6.7%) 1 (6.7%)	1 (14.3%) 1 (14.3%)	1.000 1.000
Sepsis	2 (13.3%)	1 (14.3%)	1.000
MODS	0	1 (14.3%)	0.318