Surgical Strategy For Chronic Type B Aortic Dissection By Open Stent Graft In Endovascular Era
Akitoshi Takazawa, MD, Toshihisa Asakura, MD, Akihiro Yoshitake, MD, Chiho Tokunaga, MD, Hiroyuki Nakajima, MD, Atsushi Iguchi, MD.
Saitama medical university International medical center, Hidaka city, Japan.
[Background] Medical management remains the standard treatment modality for chronic type B aortic dissection(CTBAD). The timing and choice of surgical method for CTBAD is still a topic of much debate. The role of thoracic endovascular repair(TEVAR) for CTBAD remais controversial. Recently, a total aortic arch replacement using open stent graft(TAR+OSG) as a means of preventing distant aortic event is performed. The purpose of this study is to assess and compare the clinical outcome of TAR+OSG via sternotomy compared with TEVAR for CTBAD.[Methods] From April 2007 to January 2019, we retrospectively reviewed 83 consecutive patients underwent TEVAR for UTBAD. We divided two groups; TA group was patients who underwent TAR+OSG and TE group was patients who underwent TEVAR. Group TA was 22 patients and group TE was 61 patients. Preoperative and postoperative computed tomography(CT) studies were retrospectively analyzed for sizes of the max diameter. Average follow up period was 4.3 years.[Results] All operative mortality was none, but one case was in-hospital mortality was in Group TA. There was no difference in all complications such as stroke(p=0.39), paraplegia(p=0.55). Difference in preoperative factors was Marfan syndrome in Group TE(TA:3, TE:0, p<0.01), an age(TA:60±11, TE:68±12, p<0.01), intervals between the onset and operation(TA:13.9±32.4 year, TE:1.7±0.3 year, p<0.01) and the max diameter in preoperative CT(TA:51±7mm, TE:50±9mm, p<0.01).There was a significant difference in long term survival rate(p=0.02) and the thoracic reintervention rate (p=0.03). The postoperative adverse event in Group TE was 4 of retrospective type A aortic dissection, 2 of stent graft infection and 2 of fistula of aorto-esophagus.[Conclusions]No absolute benefit of TEVAR over TAR+OSG for CTBAD remains certain. Some fatal complications such as RTAD and AEF by aneurysmal dilation was seen in Group TE on long term. However TAR+OSG is exempt neither from reintervention nor neurological complication.Each surgical strategy has its place and the patient selection is most important. Some preoperative factors should be concerned for each cases.
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