Exploring the impact of stanford type B aortic dissection complicated by an isolated left vertebral artery on the prognosis after thoracic endovascular aortic repair_CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Authors：

SHEN Yinzhi ^1,2 , HUANG Bin ¹ ,  YUAN Ding ¹ ,  ZHAO Jichun ¹

1. Division of Vascular Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu 610041, P. R. China;
2. West China Clinical Medical College, Sichuan University, Chengdu 610041, P. R. China;

Corresponding author：

YUAN Ding, Email: yuanding@wchscu.cn; ZHAO Jichun, Email: zhaojc3@163.com

Keywords：

aortic dissection; thoracic endovascular aortic repair; isolated left vertebral artery; aortic-related death; adverse aortic remodeling

DOI：

10.7507/1007-9424.202403028

Video：

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Objective To investigate the impact of anatomical variations of the isolated left vertebral artery (ILVA) on clinical outcomes and imaging outcomes in patients with Stanford type B aortic dissection (TBAD) who underwent thoracic endovascular aortic repair. Methods The clinical data of patients with TBAD in West China Hospital, Sichuan University from January 2016 to December 2023 were collected, and the differences of clinical outcomes and imaging outcomes between patients with and without ILVA were compared. Results Based on the inclusion criteria and the result of propensity score-based matching, 82 patients with TBAD were included, including 17 patients with ILVA (ILVA group) and 65 patients without ILVA (control group). There was no significant difference between the two groups in terms of the radiological and surgical information (P>0.05). The median time of the follow-up for these 82 patients were 37 months, during which there were no significant differences in aortic-related death, aortic event, stroke, adverse aortic remodeling, type Ⅰ A endoleak, and retrograde progression between the two groups (P>0.05). Compared with the control group, the re-intervention rate [HR=2.56, 95%CI (1.55, 8.11), P=0.03] and the incidence of type Ⅱ internal leakage [OR=1.36, 95%CI (1.08, 2.11), P=0.04] in the ILVA group were higher. Conclusions No significant differences were observed for ILVA patients in terms of serious adverse events such as aortic-related death and retrograde progression, comparing with the patients with normal aortic arch. However, the patients with ILVA were more susceptible to complications such as reintervention and type Ⅱ endoleak, which warranted the necessity of intensive postoperative follow-up for these patients.

Citation： SHEN Yinzhi, HUANG Bin, YUAN Ding, ZHAO Jichun. Exploring the impact of stanford type B aortic dissection complicated by an isolated left vertebral artery on the prognosis after thoracic endovascular aortic repair. CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY, 2024, 31(8): 961-967. doi: 10.7507/1007-9424.202403028 Copy

1.	Clouse WD, Hallett JW Jr, Schaff HV, et al. Acute aortic dissection: population-based incidence compared with degenerative aortic aneurysm rupture. Mayo Clin Proc, 2004, 79(2): 176-180.
2.	Landenhed M, Engström G, Gottsäter A, et al. Risk profiles for aortic dissection and ruptured or surgically treated aneurysms: a prospective cohort study. J Am Heart Assoc, 2015, 4(1): e001513. doi: 10.1161/JAHA.114.001513.
3.	Ding H, Zhu Y, Wang H, et al. Management of type B aortic dissection with an isolated left vertebral artery. J Vasc Surg, 2019, 70(4): 1065-1071.
4.	Yamashiro S, Kuniyoshi Y, Arakaki K, et al. Total arch replacement with associated anomaly of the left vertebral artery. Ann Thorac Cardiovasc Surg, 2010, 16(3): 216-219.
5.	Clough RE, Barillà D, Delsart P, et al. Editor’s choice—long-term survival and risk analysis in 136 consecutive patients with type B aortic dissection presenting to a single centre over an 11 year period. Eur J Vasc Endovasc Surg, 2019, 57(5): 633-638.
6.	Lombardi JV, Hughes GC, Appoo JJ, et al. Society for vascular surgery (SVS) and society of thoracic surgeons (STS) reporting standards for type B aortic dissections. J Vasc Surg, 2020, 71(3): 723-747.
7.	Qi R, Sun L, Zhu J, et al. Total arch replacement in patients with aortic dissection with an isolated left vertebral artery. Ann Thorac Surg, 2013, 95(1): 36-40.
8.	Piffaretti G, Gelpi G, Tadiello M, et al. Transposition of the left vertebral artery during endovascular stent-graft repair of the aortic arch. J Thorac Cardiovasc Surg, 2020, 159(6): 2189-2198.
9.	Tapia GP, Zhu X, Xu J, et al. Incidence of branching patterns variations of the arch in aortic dissection in Chinese patients. Medicine (Baltimore), 2015, 94(17): e795. doi: 10.1097/MD.0000000000000795.
10.	Dudich K, Bhadelia R, Srinivasan J. Anomalous vertebral artery origin may be an independent risk factor for arterial dissection. Eur J Neurol, 2005, 12(7): 571-572.
11.	Shalhub S, Schäfer M, Hatsukami TS, et al. Association of variant arch anatomy with type B aortic dissection and hemodynamic mechanisms. J Vasc Surg, 2018, 68(6): 1640-1648.
12.	Estrera AL, Miller CC, Goodrick J, et al. Update on outcomes of acute type B aortic dissection. Ann Thorac Surg, 2007, 83(2): S842-S845. doi: 10.1016/j.athoracsur.2006.10.081.
13.	Trimarchi S, Nienaber CA, Rampoldi V, et al. Role and results of surgery in acute type B aortic dissection: insights from the International Registry of Acute Aortic Dissection (IRAD). Circulation, 2006, 114(1 Suppl): I357-I364. doi: 10.1161/CIRCULATIONAHA.105.000620.
14.	Brunkwall J, Kasprzak P, Verhoeven E, et al. Endovascular repair of acute uncomplicated aortic type B dissection promotes aortic remodelling: 1 year results of the ADSORB trial. Eur J Vasc Endovasc Surg, 2014, 48(3): 285-291.
15.	Nienaber CA, Kische S, Rousseau H, et al. Endovascular repair of type B aortic dissection: long-term results of the randomized investigation of stent grafts in aortic dissection trial. Circ Cardiovasc Interv, 2013, 6(4): 407-416.
16.	曹军生, 彭珊, 车辙, 等. 体内原位开窗联合腔内隔绝治疗主动脉弓动脉瘤合并Stanford B型主动脉夹层1例报道. 中国普外基础与临床杂志, 2023, 30(3): 350-352.
17.	崔驰, 朱智, 王弼偲. 体外开窗技术治疗EVAR术后内脏分支动脉区域主动脉夹层的技术要点. 中国普外基础与临床杂志, 2022, 29(11): 1439-1444.
18.	吉志敏, 王铁皓, 陈熹阳, 等. 马凡综合征复杂胸腹主动脉夹层动脉瘤杂交手术应用人工血管作为远端锚定区的远期良好效果. 中国普外基础与临床杂志, 2021, 28(6): 794-798.
19.	Evangelista A, Salas A, Ribera A, et al. Long-term outcome of aortic dissection with patent false lumen: predictive role of entry tear size and location. Circulation, 2012, 125(25): 3133-3141.
20.	杨祎, 朱俊明, 葛翼鹏, 等. 直视支架象鼻手术治疗合并单发左侧椎动脉的BC型主动脉夹层. 中华胸心血管外科杂志, 2017, 33(8): 482-485.
21.	熊锐, 王志维, 胡小平, 等. 急性StanfordA型主动脉夹层手术中迷走左椎动脉的处理. 实用医学杂志, 2019, 35(10): 1693-1694.
22.	Yang G, Chen H, Sun G, et al. Transposition of isolated left vertebral artery in hybrid thoracic endovascular aortic repair. Front Cardiovasc Med, 2021, 8: 783656. doi: 10.3389/fcvm.2021.783656.
23.	Zhu JM, Qi RD, Liu YM, et al. Repair of complicated type B dissection with an isolated left vertebral artery using the stented elephant trunk technique. Eur J Cardiothorac Surg, 2016, 49(3): 778-782.
24.	赖前成, 朱俊明, 葛翼鹏, 等. 孙氏手术治疗Stanford A型主动脉夹层合并单发左侧椎动脉的临床研究. 重庆医学, 2019, 48(3): 497-499, 502.
25.	Wang Z, Fang C, Song H, et al. Endovascular repair of thoracic aortic disease with isolated left vertebral artery and unfavorable proximal landing zone using fenestrated castor stent-graft. Front Cardiovasc Med, 2023, 10: 1168180. doi: 10.3389/fcvm.2023.1168180.
26.	Shen P, Li D, Wu Z, et al. Physician-modified fenestration or in situ fenestration for preservation of isolated left vertebral artery in thoracic endovascular aortic repair. Front Cardiovasc Med, 2023, 10: 1055549. doi: 10.3389/fcvm.2023.1055549.
27.	Luo ZR, Li SL, Chen LW, et al. Utilizing physician modified fenestration on the castor branched stent technique for reconstruction of an isolated left vertebral artery on the aortic arch. Sci Rep, 2024, 14(1): 4051. doi: 10.1038/s41598-024-54781-8.
28.	Zhang H, Feng J, Guo M, et al. Management of an isolated left vertebral artery on the arch during zone 2 landing thoracic endovascular aortic repair: a multicentre retrospective study. Eur J Vasc Endovasc Surg, 2023, 65(3): 330-337.

1. Clouse WD, Hallett JW Jr, Schaff HV, et al. Acute aortic dissection: population-based incidence compared with degenerative aortic aneurysm rupture. Mayo Clin Proc, 2004, 79(2): 176-180.
2. Landenhed M, Engström G, Gottsäter A, et al. Risk profiles for aortic dissection and ruptured or surgically treated aneurysms: a prospective cohort study. J Am Heart Assoc, 2015, 4(1): e001513. doi: 10.1161/JAHA.114.001513.
3. Ding H, Zhu Y, Wang H, et al. Management of type B aortic dissection with an isolated left vertebral artery. J Vasc Surg, 2019, 70(4): 1065-1071.
4. Yamashiro S, Kuniyoshi Y, Arakaki K, et al. Total arch replacement with associated anomaly of the left vertebral artery. Ann Thorac Cardiovasc Surg, 2010, 16(3): 216-219.
5. Clough RE, Barillà D, Delsart P, et al. Editor’s choice—long-term survival and risk analysis in 136 consecutive patients with type B aortic dissection presenting to a single centre over an 11 year period. Eur J Vasc Endovasc Surg, 2019, 57(5): 633-638.
6. Lombardi JV, Hughes GC, Appoo JJ, et al. Society for vascular surgery (SVS) and society of thoracic surgeons (STS) reporting standards for type B aortic dissections. J Vasc Surg, 2020, 71(3): 723-747.
7. Qi R, Sun L, Zhu J, et al. Total arch replacement in patients with aortic dissection with an isolated left vertebral artery. Ann Thorac Surg, 2013, 95(1): 36-40.
8. Piffaretti G, Gelpi G, Tadiello M, et al. Transposition of the left vertebral artery during endovascular stent-graft repair of the aortic arch. J Thorac Cardiovasc Surg, 2020, 159(6): 2189-2198.
9. Tapia GP, Zhu X, Xu J, et al. Incidence of branching patterns variations of the arch in aortic dissection in Chinese patients. Medicine (Baltimore), 2015, 94(17): e795. doi: 10.1097/MD.0000000000000795.
10. Dudich K, Bhadelia R, Srinivasan J. Anomalous vertebral artery origin may be an independent risk factor for arterial dissection. Eur J Neurol, 2005, 12(7): 571-572.
11. Shalhub S, Schäfer M, Hatsukami TS, et al. Association of variant arch anatomy with type B aortic dissection and hemodynamic mechanisms. J Vasc Surg, 2018, 68(6): 1640-1648.
12. Estrera AL, Miller CC, Goodrick J, et al. Update on outcomes of acute type B aortic dissection. Ann Thorac Surg, 2007, 83(2): S842-S845. doi: 10.1016/j.athoracsur.2006.10.081.
13. Trimarchi S, Nienaber CA, Rampoldi V, et al. Role and results of surgery in acute type B aortic dissection: insights from the International Registry of Acute Aortic Dissection (IRAD). Circulation, 2006, 114(1 Suppl): I357-I364. doi: 10.1161/CIRCULATIONAHA.105.000620.
14. Brunkwall J, Kasprzak P, Verhoeven E, et al. Endovascular repair of acute uncomplicated aortic type B dissection promotes aortic remodelling: 1 year results of the ADSORB trial. Eur J Vasc Endovasc Surg, 2014, 48(3): 285-291.
15. Nienaber CA, Kische S, Rousseau H, et al. Endovascular repair of type B aortic dissection: long-term results of the randomized investigation of stent grafts in aortic dissection trial. Circ Cardiovasc Interv, 2013, 6(4): 407-416.
16. 曹军生, 彭珊, 车辙, 等. 体内原位开窗联合腔内隔绝治疗主动脉弓动脉瘤合并Stanford B型主动脉夹层1例报道. 中国普外基础与临床杂志, 2023, 30(3): 350-352.
17. 崔驰, 朱智, 王弼偲. 体外开窗技术治疗EVAR术后内脏分支动脉区域主动脉夹层的技术要点. 中国普外基础与临床杂志, 2022, 29(11): 1439-1444.
18. 吉志敏, 王铁皓, 陈熹阳, 等. 马凡综合征复杂胸腹主动脉夹层动脉瘤杂交手术应用人工血管作为远端锚定区的远期良好效果. 中国普外基础与临床杂志, 2021, 28(6): 794-798.
19. Evangelista A, Salas A, Ribera A, et al. Long-term outcome of aortic dissection with patent false lumen: predictive role of entry tear size and location. Circulation, 2012, 125(25): 3133-3141.
20. 杨祎, 朱俊明, 葛翼鹏, 等. 直视支架象鼻手术治疗合并单发左侧椎动脉的BC型主动脉夹层. 中华胸心血管外科杂志, 2017, 33(8): 482-485.
21. 熊锐, 王志维, 胡小平, 等. 急性StanfordA型主动脉夹层手术中迷走左椎动脉的处理. 实用医学杂志, 2019, 35(10): 1693-1694.
22. Yang G, Chen H, Sun G, et al. Transposition of isolated left vertebral artery in hybrid thoracic endovascular aortic repair. Front Cardiovasc Med, 2021, 8: 783656. doi: 10.3389/fcvm.2021.783656.
23. Zhu JM, Qi RD, Liu YM, et al. Repair of complicated type B dissection with an isolated left vertebral artery using the stented elephant trunk technique. Eur J Cardiothorac Surg, 2016, 49(3): 778-782.
24. 赖前成, 朱俊明, 葛翼鹏, 等. 孙氏手术治疗Stanford A型主动脉夹层合并单发左侧椎动脉的临床研究. 重庆医学, 2019, 48(3): 497-499, 502.
25. Wang Z, Fang C, Song H, et al. Endovascular repair of thoracic aortic disease with isolated left vertebral artery and unfavorable proximal landing zone using fenestrated castor stent-graft. Front Cardiovasc Med, 2023, 10: 1168180. doi: 10.3389/fcvm.2023.1168180.
26. Shen P, Li D, Wu Z, et al. Physician-modified fenestration or in situ fenestration for preservation of isolated left vertebral artery in thoracic endovascular aortic repair. Front Cardiovasc Med, 2023, 10: 1055549. doi: 10.3389/fcvm.2023.1055549.
27. Luo ZR, Li SL, Chen LW, et al. Utilizing physician modified fenestration on the castor branched stent technique for reconstruction of an isolated left vertebral artery on the aortic arch. Sci Rep, 2024, 14(1): 4051. doi: 10.1038/s41598-024-54781-8.
28. Zhang H, Feng J, Guo M, et al. Management of an isolated left vertebral artery on the arch during zone 2 landing thoracic endovascular aortic repair: a multicentre retrospective study. Eur J Vasc Endovasc Surg, 2023, 65(3): 330-337.

CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Exploring the impact of stanford type B aortic dissection complicated by an isolated left vertebral artery on the prognosis after thoracic endovascular aortic repair

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