Print this pageAcute Descending Thoracic Aortic Dissection (ADTAD): When is surgical intervention indicated? Can endovascular techniques be used instead?
Girma Tefera, MD, Charles W. Acher, John R. Hoch, MD, Matthew Mell, MD and William D. Turnipseed, MD
Surgery, University of Wisconsin, Madison, WI
Objectives: Although the mainstay of managing acute descending thoracic aortic dissection remains medical. Certain patients will require emergency surgery for complications of rupture or ischemia. This study evaluates factors that affect outcome and determines which patients previously treated surgically could have been eligible for endovascular repair.
Methods:A single center retrospective study of patients who presented with clinical signs of ADTAD and confirmed by MRI/CT were included. All patients were initially admitted to an intensive care unit and medically managed to maintain systolic blood pressure < 120 mmHg and heart rate < 70 beats per minute. Two treatment groups were identified: Group 1 (medical treatment only), Group 2 (medical treatment with emergent surgery). Patient demographics and clinical data were correlated with 30 day group morbidity and mortality and the need for emergency surgery. A retrospective review of CT or MRI images of Group 2 patients was also preformed to determine if currently available endovascular treatments could have been appropriate. Fishers exact test was used for comparison and a p-value less than 0.05 was considered significant.
Results: Between 1991- 2005, 83 patients were treated for ADTAD. 55 were male ,mean age of 67 (range 38-85). Sixty-eight patients (82%) had hypertension, 3 (3.6%) had Marfan’s syndrome, and 51 (62%) were smokers. Twenty-five (32%) of the patients were on beta-blockers prior to onset symptoms. Back pain was the most common symptom at presentation (72.2%). Ninteen patients (23%) required emergency surgery: 12 for rupture or impending rupture in, 4 for mesenteric ischemia and 3 for lower extremity ischemia. The need for emergency surgery was significantly higher in smokers (p=0.03), and patients who were not on beta-blocker therapy prior to the onset of symptoms (p=0.023). The combined group morbidity and mortality rates were 33% and 9.6% respectively. Morbidity in Group 1(23.8%) was significantly lower than Group 2 (63%) (p=0.00227). The mortality rate was significantly higher in Group 2 (31.5%) compared to Group 1 (1.6%) (p=0.0004). Age > 70 or gender did not significantly affect mortality. Previous abdominal aneurysm repair (p= 0.018), tobacco use (p=0.039) and the presence of leg pain at initial presentation (p=0.013) were associated with an increase in the overall mortality. Based on a re-review of radiologic data, 11 of the 13 patients in Group 2 could have been treated with currently available endovascular grafts.
Conclusions: Intensive medical therapies are effective in preventing early mortality associated with ADTAD. Predictably, the need for emergent surgery carries a high morbidity and mortality rate. Most of the patients in this series requiring emergent surgical treatment could have been candidates for endovascular therapy if it were available.