Discordance of aortic remodeling with clinical outcomes in patients ...

doi:10.1510/icvts.2011.274241

Interactive CardioVascular and Thoracic Surgery 13 (2011) 203-204

www.icvts.org

Brief communication - Aortic and aneurysmal

Discordance of aortic remodeling with clinical outcomes in patients treated with endovascular repair for uncomplicated type B aortic dissection Larry E. Millera,*, Lee M. Piersonb Miller Scientific Consulting, Inc., Biltmore Lake, NC, USA Department of Medicine, Duke Hospital, Durham, NC, USA

a b

Received 8 April 2011; accepted 9 May 2011

Abstract Uncomplicated type B aortic dissection is managed with anti-impulse therapy since surgery offers no additional long-term survival advantage. In recent years, thoracic endovascular repair (TEVAR) has been forwarded as a treatment strategy that may retard aortic growth, lower rupture risk, and improve clinical outcome compared to medical management in patients with uncomplicated type B aortic dissection. Although aortic remodeling often serves as a surrogate measure of treatment success in trials of aortic dissection, there is, in fact, little evidence to suggest that aortic remodeling confers a clinical advantage in this patient cohort. TEVAR likely will not be widely recommended for the patient with uncomplicated type B aortic dissection until a prospective comparative clinical trial demonstrates a clear clinical advantage of TEVAR over medical management. Measures of aortic remodeling are poor surrogate measures of treatment success in this patient population.  2011 Published by European Association for Cardio-Thoracic Surgery. All rights reserved. Keywords: Aortic; Dissection; Endovascular

1. Introduction

*Corresponding author. Miller Scientific Consulting, Inc., 422 Mountain Wasp Drive, Biltmore Lake, NC 28715, USA. Tel.: +1-928-6079657; fax: +1928-2683563. E-mail address: [email protected] (L.E. Miller).  2011 Published by European Association for Cardio-Thoracic Surgery

Brief Communication

Aortic dissection affects five to 30 people per million each year and is responsible for significant mortality and morbidity [1–4]. Uncomplicated type B aortic dissection is managed with anti-impulse therapy since surgery offers no additional long-term survival advantage [5]. In recent years, thoracic endovascular repair (TEVAR) has been forwarded as a treatment strategy that may retard aortic growth, lower rupture risk, and improve clinical outcome compared to medical management in patients with uncomplicated type B aortic dissection. The premise of TEVAR is that stent graft placement over the primary entry tear will prevent blood flow into the false lumen causing thrombosis and depressurization while redirecting the circulation through the true lumen. Although aortic remodeling often serves as a surrogate measure of treatment success in trials of aortic dissection, there is, in fact, little evidence to suggest that aortic remodeling confers a clinical advantage in this patient cohort. A single randomized trial has been conducted to evaluate the efficacy of TEVAR for uncomplicated type B aortic dissection [6]. Although radiographic endpoints suggestive

of treatment success strongly favored TEVAR survivors, this group enjoyed no corresponding clinical benefit. Specifically, the TEVAR group had a 33% larger true lumen diameter and a 47% smaller false lumen diameter (both P