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Endovascular Stent-Graft Placement in Patients with Stanford Type B Aortic Dissection in China: A Systematic Review

  • Junwei Wang
    Affiliations
    Department of Vascular Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China

    Department of Vascular Surgery, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
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  • Yonghui Li
    Affiliations
    Department of Vascular Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
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  • Yongxin Li
    Affiliations
    Department of Vascular Surgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
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  • Zefang Ren
    Affiliations
    The School of Public Health, Sun Yat-sen University, Guangzhou, Guangdong, China
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  • Peng Chen
    Affiliations
    Department of Gastrointestinal Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
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  • Xueke Qian
    Affiliations
    Department of Vascular Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
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  • Shenming Wang
    Correspondence
    Correspondence to: Jinsong Wang, PhD or Shenming Wang, PhD, Department of Vascular Surgery, The First Affiliated Hospital of Sun Yat-sen University, No. 58 Zhongshan Road 2, Guangzhou, Guangdong 510080, China
    Affiliations
    Department of Vascular Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
    Search for articles by this author
  • Jinsong Wang
    Correspondence
    Correspondence to: Jinsong Wang, PhD or Shenming Wang, PhD, Department of Vascular Surgery, The First Affiliated Hospital of Sun Yat-sen University, No. 58 Zhongshan Road 2, Guangzhou, Guangdong 510080, China
    Affiliations
    Department of Vascular Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
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Open AccessPublished:July 12, 2016DOI:https://doi.org/10.1016/j.avsg.2016.04.006

      Background

      Improvements in stent-graft devices and increasing clinical experience with the technique have improved outcomes and expanded clinical indications in patients with Stanford type B aortic dissection (AD) in China. However, the evolution of and modifications to stent grafts have not been reviewed. The aim of this study was to summarize all available published data on technical success, potential benefits, complications, stent evolution, and survival rates associated with endovascular stent-graft placements in patients with Stanford type B AD in China.

      Methods

      We performed comprehensive searches of the Chinese-language medical literature in Chinese Biomedical Database, China National Knowledge Infrastructure, and Wanfang Data and of the English-language medical literature in PubMed, Web of Science, and the Cochrane Library. This systematic review was based on all retrospective studies assessing outcomes of Stanford type B AD treated with endovascular stent-graft placement in China.

      Results

      A total of 153 retrospective studies that included 8,694 cases were analyzed in this study. Procedure success was reported in 99.7 ± 0.1% of patients. Overall complications were reported in 19.1 ± 0.6% of patients. Postoperative endoleaks occurred in 7.2 ± 0.3% of patients. Major complications were reported in 3.2 ± 0.2% of patients, with a neurological complication rate of 1.3 ± 0.1%. Periprocedural stroke occurred more frequently than did paraplegia (0.8 ± 0.1% vs. 0.1 ± 0.04%). Overall complications were significantly greater in patients treated with first-generation stents than in those treated with second-generation stents (25.1 ± 1.2% vs. 9.5 ± 0.9%, P < 0.001). The in-hospital mortality rate was 1.6 ± 0.1%. In addition, 1.8 ± 0.2% of patients died during a mean follow-up period of 29.4 ± 13.5 months. The Kaplan–Meier estimates of the overall survival rate were 99.0 ± 0.1% at 30 days, 98.5 ± 0.2% at 6 months, 98.4 ± 0.2% at 1 year, 98.1 ± 0.2% at 2 years, and 97.9 ± 0.2% at 5 years.

      Conclusions

      Endovascular stent-graft placement is feasible and has a high technique success rate as well as favorable neurological complication and survival rates when used to treat Stanford type B AD. The new generation of stent grafts appears to have favorable in-hospital and follow-up outcomes.

      Introduction

      In a recent expert consensus document, endovascular stent-graft placement was recommended as the optimal treatment for complicated Stanford type B aortic dissection (AD).
      • Svensson L.G.
      • Kouchoukos N.T.
      • Miller D.C.
      • et al.
      Expert consensus document on the treatment of descending thoracic aortic disease using endovascular stent-grafts.
      • Fattori R.
      • Cao P.
      • De Rango P.
      • et al.
      Interdisciplinary expert consensus document on management of type B aortic dissection.
      Uncomplicated type B AD has traditionally been managed medically.
      • Svensson L.G.
      • Kouchoukos N.T.
      • Miller D.C.
      • et al.
      Expert consensus document on the treatment of descending thoracic aortic disease using endovascular stent-grafts.
      • Fattori R.
      • Cao P.
      • De Rango P.
      • et al.
      Interdisciplinary expert consensus document on management of type B aortic dissection.
      • Glower D.D.
      • Fann J.I.
      • Speier R.H.
      • et al.
      Comparison of medical and surgical therapy for uncomplicated descending aortic dissection.
      Two randomized controlled trials (RCTs) comparing endovascular repair with medical management for type B AD demonstrated favorable aortic modeling
      • Nienaber C.A.
      • Rousseau H.
      • Eggebrecht H.
      • et al.
      Randomized comparison of strategies for type B aortic dissection: the INvestigation of STEnt Grafts in Aortic Dissection (INSTEAD) trial.
      • Nienaber C.A.
      • Kische S.
      • Akin I.
      • et al.
      Strategies for subacute/chronic type B aortic dissection: the Investigation of Stent Grafts in Patients with type B Aortic Dissection (INSTEAD) trial 1-year outcome.
      • Nienaber C.A.
      • 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.
      • Brunkwall J.
      • Lammer J.
      • Verhoeven E.
      • et al.
      ADSORB: a study on the efficacy of endovascular grafting in uncomplicated acute dissection of the descending aorta.
      • 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.
      and improved 5-year survival rates.
      • Nienaber C.A.
      • 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.
      Increasing evidence has demonstrated the efficacy, technical feasibility, and clinical safety of endovascular repair for type B AD to reduce complications and mortality associated with conventional open surgical repair.
      • Luebke T.
      • Brunkwall J.
      Outcome of patients with open and endovascular repair in acute complicated type B aortic dissection: a systematic review and meta-analysis of case series and comparative studies.
      • Xenos E.S.
      • Minion D.J.
      • Davenport D.L.
      • et al.
      Endovascular versus open repair for descending thoracic aortic rupture: institutional experience and meta-analysis.
      Improvements in stent-graft devices and increasing experience with the technique have resulted in better outcomes and expanded clinical indications in patients with type B AD in China. Type B AD has been treated with stent grafts for nearly 2 decades. The treatment has recently been refined and improved so that both domestic and imported stent grafts are now used, and both the stent length and design have been modified. However, these modifications have not been reviewed.
      Although several single-center studies have demonstrated favorable procedural safety and outcomes for endovascular repair, RCTs have not yet been conducted in China. Therefore, we systemically reviewed all relevant literature published by Chinese authors and performed a systematic review to analyze all available published data on the technical success, potential benefits, complications, stent evolution, and survival rates associated with endovascular stent-graft placement for type B AD.

      Materials and Methods

      Literature Search Strategy

      A literature search was performed in August 2014 without publication date, type, or language restrictions. We used the terms “aortic dissection,” “type B,” “DeBakey III,” “endovascular,” and “stent” as key words in a comprehensive search of the Chinese-language medical literature in Chinese Biomedical Database, China National Knowledge Infrastructure, and Wanfang Data. Aortic dissection, type B, DeBakey III, endovascular, stent, and “China” were also used as key words in a comprehensive search of the English-language medical literature in PubMed, Web of Science, and the Cochrane Library. The related article's function was used to broaden the search. Additional studies were manually retrieved from the reference lists of all retrieved studies.

      Inclusion and Exclusion Criteria

      Several criteria were used to determine whether an article qualified for further analysis. Publications focusing on retrograde endovascular stent-graft treatment into the descending thoracic aorta for type B AD were selected for data extraction. Publications including patients with other thoracic aortic pathologies (e.g., thoracic aortic aneurysms) were discarded. Articles reporting antegrade surgical (open) stent-graft placement through the aortic arch or hybrid surgery were excluded. Case reports, letters to the editor, editorials, review articles, and animal experimental studies were not included. Studies in which fewer than 10 patients with type B AD were treated with stent grafts were excluded. Articles containing insufficient data (<25% of predefined variables) were also excluded. To avoid duplicate reports from a single center, only articles with the most recent number of patients or the most information on clinical characteristics or outcomes were included.

      Data Extraction

      A standardized protocol for data extraction that includes 53 predefined variables regarding clinical characteristics, procedural data, and in-hospital and follow-up outcomes was introduced by Eggebrecht et al.
      • Eggebrecht H.
      • Nienaber C.A.
      • Neuhäuser M.
      • et al.
      Endovascular stent-graft placement in aortic dissection: a meta-analysis.
      Each article was analyzed using a modified standardized protocol that included 65 predefined variables (Appendix Table A1). Two authors (Wang and Li) independently extracted and summarized the data. Consensus was attained by 2 adjudicating senior authors when discrepancies occurred. Unspecified information was classified as not available, and therefore the number of patients (denominator) varied for each specific variable included in the analysis.

      Statistical Analysis

      The number of events divided by the number of treated patients with available data was used to calculate the rates of events. The approach used to calculate the individual rates for different studies and combine these rates into a weighted average produced identical results when the weights were defined as the proportion of available patients provided in a specific study. The results are presented as the mean ± standard deviation or the median and range. Two-sided chi-squared tests for categorical variables and 2-sided Student's t-tests for continuous variables were used to compare patients with type B AD treated with first- or second-generation stents. Comparisons between patients with respect to publication date or operator experience were performed using 2-sided chi-squared tests for categorical variables. The Kaplan–Meier nonparametric method was used to generate estimates of survival at 30 days, 6 months, 1 year, 2 years, and 5 years, and these survival rates were compared using the log-rank test. Only studies reporting the exact time of events were included in the Kaplan–Meier analysis. A P value <0.05 was considered statistically significant. SPSS 13.0 statistical software was used for all statistical analyses.

      Definition

      Two classification schemes were used to describe AD. Stanford type B dissection originates in the descending aorta distal to the origin of the left subclavian artery and therefore encompasses DeBakey type III. Dissection was considered acute if it occurred up to 14 days after the onset of symptoms and chronic if it occurred after 14 days. Complications were classified as major if they were life-threatening or required emergency management (e.g., stroke or access complications requiring surgical revision), while complications that might resolve without further treatment (e.g., infection of the access site, transient renal failure not requiring dialysis) were defined as minor. Technical success was defined by the technically successful deployment of the endoprosthesis at the intended target location. Any death that occurred suddenly or could not be related to other causes was attributed to aortic rupture. Reintervention was defined as the need for any additional endovascular stent-graft procedures or surgical conversion. Procedure-related complications included complications related to endovascular repair (e.g., dissection rupture, retrograde dissection, organ or peripheral artery malperfusion, stroke for subclavian artery occlusion, and type I endoleak). Stent-graft exclusion syndrome, also known as postimplantation syndrome, comprises fever; increased white blood cell count and C-reactive protein level; decreased platelet count; and increased interleukin (interleukin-6, interleukin-8, and interleukin-10) levels. Centers with a published total number of patients beyond the median (>32 patients) were considered more experienced than those with a total number below the median. In addition, the results of stent-graft placement were analyzed with respect to study publication date. Most of the second-generation imported stent grafts from companies such as Medtronic and Cook were introduced into the Chinese market in 2008. Therefore, studies published between 2002 and 2008 represented earlier experience, and studies published between 2009 and 2014 represented more recent experience. Centers began to fully use the improved second-generation domestic or imported stent grafts at the beginning of 2009 in China; therefore, surgeries performed before and after 2009 were considered to have used first- and second-generation stent grafts, respectively.

      Results

      Study Selection

      A total of 153 studies (Appendix References) that included 8,694 cases of AD fulfilled the inclusion and exclusion criteria and were included in the final analysis (Fig. 1); 8,415 (96.8%) cases had type B AD (Appendix Table A2). An examination of the references provided in these studies did not reveal any additional studies for evaluation.
      Figure thumbnail gr1
      Fig. 1Flow diagram of the study identification and inclusion and exclusion criteria.

      Patient Characteristics

      The characteristics of the patients in the included studies are shown in Table I. The majority (7,901, 93.9%) of the 8,415 patients with type B AD underwent endovascular repair. Sixty-five of 7,775 patients (0.8%) had evidence of aortic rupture based on computed tomographic angiography, magnetic resonance angiography, or digital subtraction angiography. Of the 7,072 patients, 404 (6.1%) patients were diagnosed with complicated type B AD.
      Table IPatient characteristics
      VariablesNumber of publications with available data (n)Overall number of patients with available data (n)Number of events or cases (n, %)
      Total no. of patients reported1538,694
      No. of patients with type B AD1538,41596.8%
      No. of patients with type B AD per study1535532 (10–578)
      Median.
      Patient age (years)1326,89053.6 ± 4.7
      Male gender1397,0705,722 (80.9 ± 0.5%)
      Acute dissection804,8402,837 (58.6 ± 0.7%)
      Presenting with rupture1497,77565 (0.8 ± 0.1%)
      Hypertension1306,7235,560 (82.7 ± 0.5%)
      Complicated type B AD1397,072404 (6.1 ± 0.3%)
      a Median.

      Procedural and In-Hospital Data

      Technical success was achieved in 99.7 ± 0.1% of the treated patients. Surgical conversion (18/7901) was required in 0.2 ± 0.1% of patients (Table II), and adjunctive endovascular procedures were performed in 2.6 ± 0.2% of patients. In-hospital overall complications were reported in 19.1 ± 0.6% of patients. Major complications occurred in 3.2 ± 0.2% of patients, while minor complications occurred in 16.2 ± 0.6% of patients. Postoperative endoleaks occurred in 7.2 ± 0.3% of patients, with type I, II, III, and IV endoleaks occurring at rates of 4.2 ± 0.3%, 0.3 ± 0.1%, 0.2 ± 0.1%, and 0.4 ± 0.1%, respectively. Procedure-related complications were reported in 7.1 ± 0.4% of patients, including retrograde type A AD in 0.3 ± 0.1% of patients and access complications in 1.1 ± 0.1% of patients. Among patients with overall neurological complications (1.3 ± 0.1%), 0.8 ± 0.1% suffered stroke, and paraplegia occurred in 0.1 ± 0.04% of patients. Endovascular graft exclusion syndrome occurred in 3.8 ± 0.3% of patients. Approximately 1.1 stents were used per patient, as shown in Table II, and Zenith TX-2 (Cook, USA) stents were used most frequently (Table III).
      Table IIIn-hospital data
      VariablesNumber of publications with available data (n)Overall number of patients with available data (n)Number of events or cases (n, %)
      Technical success1537,9017,881 (99.7 ± 0.1%)
      No. of stent grafts per patient784,1931.1
      Surgical conversion1537,90118 (0.2 ± 0.1%)
      Adjunctive endovascular procedures1517,645199 (2.6 ± 0.2%)
      Overall complications853,967757 (19.1 ± 0.6%)
      Major complications1156,050191 (3.2 ± 0.2%)
      Minor complications853,967644 (16.2 ± 0.6%)
      Postoperative endoleaks1406,933502 (7.2 ± 0.3%)
       Type I974,758200 (4.2 ± 0.3%)
       Type II944,48214 (0.3 ± 0.1%)
       Type III944,48210 (0.2 ± 0.1%)
       Type IV944,48220 (0.4 ± 0.1%)
      Procedure-related complications733,743264 (7.1 ± 0.4%)
       Retrograde type A AD1216,48420 (0.3 ± 0.1%)
       Access complications1065,39861 (1.1 ± 0.1%)
      Neurological complications1256,83091 (1.3 ± 0.1%)
       Stroke1266,96553 (0.8 ± 0.1%)
       Paraplegia1316,9806 (0.1 ± 0.04%)
      Endovascular graft exclusion syndrome713,601138 (3.8 ± 0.3%)
      In-hospital mortality1537,901123 (1.6 ± 0.1%)
      In-hospital mortality, aorta related1507,55148 (0.6 ± 0.1%)
      In-hospital mortality, nonaorta related1507,55158 (0.8 ± 0.1%)
      30-Day mortality1537,901131 (1.7 ± 0.1%)
      Table IIIType of stent
      Stent typesNumber of institutions (n)
      An institute may use more than one type of stent. Information on the type of stent was not reported by 48 institutions.
      Number of stents (n)
      Sum of the reported number of stents; only 78 institutions reported the exact number of stents used.
      Diameter of stent (mm)Length of stent (mm)
      Talent (Medtronic, USA)1529928–4450–200
      Valiant (Medtronic, USA)623430–36100–200
      Zenith TX-2 (Cook, USA)9310NANA
      EndoFit (LeMaitre Vascular, USA)13NANA
      Endologix (Endologix, USA)12NANA
      Relay (Bolton Medical, Spain)499NANA
      E-vita (Jotec GmbH, Germany)148NANA
      Unspecified number of each type of imported stent927326–4228–200
      Hercules (MicroPort, China)622728–4460–160
      Aegis (MicroPort, China)561NANA
      Vasoflow (Vascore, China)22430–3860–140
      Grikin TNS-X2 (Grikin, China)273NANA
      Ankura (Lifetech, China)32830–36NA
      Aortec Medical (Aortec Medical, China)820430–4680–120
      Unspecified number of each type of domestic stent1231430–4660–180
      Unspecified number of each type of imported and domestic stent131,03027–4635–200
      Unknown type of stent (imported or domestic)181,27030–4548–208
      NA, not available.
      a An institute may use more than one type of stent. Information on the type of stent was not reported by 48 institutions.
      b Sum of the reported number of stents; only 78 institutions reported the exact number of stents used.
      A total of 123 of 7,901 patients died during their hospital stay, and the overall in-hospital mortality rate was 1.6 ± 0.1%. Eight additional deaths occurred within 30 days, resulting in a 30-day mortality rate of 1.7 ± 0.1%.

      Follow-Up Data

      A total of 147 studies (6,970 patients) reported the time to follow-up, but only 52 studies (3311 patients) provided the mean follow-up period (29.4 ± 13.5 months) (Table IV). False lumen thrombosis occurred at a rate of 93.4 ± 0.5%. Late surgical conversion was required in 0.4 ± 0.1% of patients, and late adjunctive endovascular stent-graft procedures were performed in 0.1 ± 0.04% of patients. Therefore, the total reintervention rate during follow-up was 0.5 ± 0.1%. Persistent endoleaks and emerging endoleaks occurred in 2.1 ± 0.2% and 0.5 ± 0.1% of patients, respectively. Stent migration was observed in 0.1 ± 0.04% of patients. Late complications, late neurological complications, and late retrograde type A AD were reported in 8.3 ± 0.4%, 0.8 ± 0.1%, and 0.5 ± 0.1% of patients, respectively. Emerging AD occurred in 0.3 ± 0.1% of patients. Secondary endovascular procedures were performed in 1.1 ± 0.1% of patients.
      Table IVFollow-up data
      VariablesNumber of publications with available data (n)Overall number of patients with available data (n)Number of events or cases (n, %)
      Duration of follow-up (months)523,31129.4 ± 13.5
      Late surgical conversion1416,67225 (0.4 ± 0.1%)
      Late adjunctive endovascular procedures1416,6727 (0.1 ± 0.04%)
      Late complications844,605384 (8.3 ± 0.4%)
      Late neurological complications944,94841 (0.8 ± 0.1%)
      Late retrograde type A AD1376,52731 (0.5 ± 0.1%)
      Aortic rupture during follow-up1436,76879 (1.2 ± 0.1%)
      Persistent endoleaks1286,213128 (2.1 ± 0.2%)
      Emerging endoleaks1276,19728 (0.5 ± 0.1%)
      Emerging AD1386,60820 (0.3 ± 0.1%)
      Secondary endovascular procedures1426,74676 (1.1 ± 0.1%)
      False lumen thrombosis713,0062,809 (93.4 ± 0.5%)
      Stent migration1326,2797 (0.1 ± 0.04%)
      Late mortality1446,701120 (1.8 ± 0.2%)
      Late mortality, aorta-related1446,70177 (1.1 ± 0.1%)
      Late mortality, non–aorta-related1446,70143 (0.6 ± 0.1%)
      Aortic rupture during follow-up occurred in 1.2 ± 0.1% of patients, and 1.8 ± 0.2% of patients died during follow-up. Figure 2 shows the survival rates of 5142 patients with the exact time of death using the Kaplan–Meier format. The survival rates were 99.0 ± 0.1% at 30 days, 98.5 ± 0.2% at 6 months, 98.4 ± 0.2% at 1 year, 98.1 ± 0.2% at 2 years, and 97.9 ± 0.2% at 5 years.
      Figure thumbnail gr2
      Fig. 2Kaplan–Meier estimate of the overall survival of patients undergoing stent-graft placement. The numbers of available patients were 5,142 at 0 months, 3,580 at 20 months, 2,066 at 40 months, 878 at 60 months, 544 at 80 months, and 75 each at 100 and 120 months.

      Results of Endovascular Stent-Graft Placement in Relation to Publication Date

      Overall complication rates were lower in the studies published between 2009 and 2014 (18.0 ± 0.7%) than in those published between 2002 and 2008 (24.6 ± 1.7%, P < 0.001) (Table V). Neurological complication rates were higher in the more recent studies (1.5 ± 0.2% vs. 0.5 ± 0.2%, P = 0.006). No significant differences in the technical success rate or the operative or 1-year mortality rates were noted between the groups.
      Table VResults of endovascular stent-graft placement in relation to publication date
      VariablesData available (n)P value
      Statistically significant results are shown in bold.
      Publication date 2002–2008 (n = 1,344)Publication date 2009–2014 (n = 6,557)
      No. of publications35118
      Patients per center20 (10–159)
      Median.
      35 (10–578)
      Median.
      Complicated type B AD1,15047 (4.1 ± 0.6%)5,922383 (6.5 ± 0.3%)0.002
      Technical success1,34499.7 ± 0.2%6,55799.8 ± 0.1%0.953
      Overall complications67624.6 ± 1.7%3,29118.0 ± 0.7%<0.001
      Neurological complications1,1910.5 ± 0.2%5,6391.5 ± 0.2%0.006
      30-Day mortality9011.4 ± 0.4%4,2410.9 ± 0.2%0.153
      Log-rank test.
      1-Year survival72198.2 ± 0.5%3,54098.4 ± 0.2%0.558
      Log-rank test.
      a Statistically significant results are shown in bold.
      b Median.
      c Log-rank test.

      Influence of Operator Experience

      The influence of operator experience is shown in Table VI. Centers with a total number of patients above the median had lower rates of overall complications and lower 30-day mortality rates than did centers with smaller numbers of treated patients (15.3 ± 0.7% vs. 32.3 ± 1.6%, P < 0.001; 0.8 ± 0.1% vs. 1.7 ± 0.4%, P = 0.005). However, the 1-year survival rate was higher in centers with a total number of patients above the median (98.7 ± 0.2% vs. 97.5 ± 0.4%, P = 0.004).
      Table VIInfluence of operator experience
      VariablesData available (n)P value
      Statistically significant results are shown in bold.
      Endovascular experience ≤32 patients (n = 1,497)Endovascular experience >32 patients (n = 6,404)
      No. of publications7974
      Patients per center18 (10–32)
      Median.
      65 (33–578)
      Median.
      Technical success1,49799.7 ± 0.1%640499.8 ± 0.1%1.000
      Overall complications87232.3 ± 1.6%309515.3 ± 0.7%<0.001
      Neurological complications1,2111.5 ± 0.4%56191.3 ± 0.2%0.606
      30-Day mortality1,3061.7 ± 0.4%38360.8 ± 0.1%0.005
      Log-rank test.
      1-Year survival1,12797.5 ± 0.4%313498.7 ± 0.2%0.004
      Log-rank test.
      a Statistically significant results are shown in bold.
      b Median.
      c Log-rank test.

      First- Versus Second-Generation Stent Grafts

      Of the 153 studies, 61 (39.9%) reported treatment with both first- and second-generation stents, 66 (43.1%) used only first-generation stents, and 26 (17.0%) used only second-generation stents (Table VII). There were no significant differences in the major points of evaluation between the first- and second-generation stent groups (Table VII). The second-generation stent group included a larger proportion of younger patients, and overall complications (9.5 ± 0.9% vs. 25.1 ± 1.2%, P < 0.001), major complications (2.0 ± 0.4% vs. 3.2 ± 0.4%, P = 0.042), minor complications (7.4 ± 0.8% vs. 21.7 ± 1.1%, P < 0.001), postoperative endoleaks (5.0 ± 0.6% vs. 8.6 ± 0.6%, P < 0.001), procedure-related complications (3.6 ± 0.6% vs. 6.8 ± 0.8%, P = 0.001), late complications (5.3 ± 0.7% vs. 9.1 ± 0.7%, P < 0.001), late neurological complications (0.2 ± 0.1% vs. 0.8 ± 0.2%, P = 0.032), and persistent endoleaks (0.8 ± 0.3% vs. 2.2 ± 0.3%, P = 0.003) were reported less frequently in the second-generation stent group. However, the outcomes of adjunctive endovascular procedures and secondary endovascular procedures were poorer in the second-generation stent group (2.8 ± 0.4% vs. 1.5 ± 0.2%, P = 0.005; 2.0 ± 0.4% vs. 0.7 ± 0.2%, P < 0.001). The overall survival rates for the first-generation stent group were 99.0 ± 0.2% at 30 days, 98.6 ± 0.3% at 6 months, 98.4 ± 0.3% at 1 year, 98.3 ± 0.3% at 2 years, and 98.1 ± 0.4% at 5 years. The overall survival rates for the second-generation stent group were 99.3 ± 0.2% at 30 days, 99.1 ± 0.3% at 6 months, 99.1 ± 0.3% at 1 year, 98.8 ± 0.3% at 2 years, and 98.8 ± 0.3% at 5 years (Table VII).
      Table VIIComparison of first- and second-generation stent grafts
      VariablesData available (n)P value
      Statistically significant results are shown in bold.
      First-generation stent grafts (n = 2,989)Second-generation stent grafts (n = 1,547)
      Age (years)2,42952.8 ± 5.81,31046.6 ± 2.5<0.001
      Male gender2,57981.7 ± 0.8%1,32982.6 ± 1.0%0.497
      Technical success2,98999.7 ± 0.1%1,54799.9 ± 0.1%0.202
      No. of stent grafts per patient1,3251.11,0651.0
      In-hospital surgical conversion2,9890.4 ± 0.1%1,5470.1 ± 0.1%0.086
      Adjunctive endovascular procedures2,7331.5 ± 0.2%1,5472.8 ± 0.4%0.005
      Overall complications1,31325.1 ± 1.2%1,0179.5 ± 0.9%<0.001
      Major complications2,3083.2 ± 0.4%1,2102.0 ± 0.4%0.042
      Minor complications1,31321.7 ± 1.1%1,0177.4 ± 0.8%<0.001
      Postoperative endoleaks2,6328.6 ± 0.6%1,3535.0 ± 0.6%<0.001
      Procedure-related complications9966.8 ± 0.8%9473.6 ± 0.6%0.001
       Retrograde type A AD2,3200.4 ± 0.1%1,3520.1 ± 0.1%0.152
       Access complications1,8541.0 ± 0.2%1,1690.5 ± 0.2%0.167
      Neurological complications2,6360.8 ± 0.2%1,3841.2 ± 0.3%0.179
       Stroke2,6360.5 ± 0.1%1,3840.4 ± 0.2%0.676
       Paraplegia2,7470%1,4120.1 ± 0.1%0.340
      Endovascular graft exclusion syndrome1,2721.7 ± 0.4%1,0171.7 ± 0.4%0.915
      Late surgical conversion2,4780.4 ± 0.1%1,3440.2 ± 0.1%0.425
      Late adjunctive endovascular procedures2,4780.1 ± 0.1%1,3440.1 ± 0.1%1.000
      Late complications1,7549.1 ± 0.7%9995.3 ± 0.7%<0.001
      Late neurological complications1,8620.8 ± 0.2%1,0860.2 ± 0.1%0.032
      Late retrograde type A AD2,5400.4 ± 0.1%1,3060.4 ± 0.2%0.819
      Emerging AD2,5400.4 ± 0.1%1,3060%0.072
      Secondary endovascular procedures2,5520.7 ± 0.2%1,3442.0 ± 0.4%<0.001
      Aortic rupture during follow-up2,5521.1 ± 0.2%1,3440.7 ± 0.2%0.242
      Persistent endoleaks2,2612.2 ± 0.3%1,2190.8 ± 0.3%0.003
      Emerging endoleaks2,2450.5 ± 0.2%1,2190.3 ± 0.2%0.488
      Stent migration2,4690.2 ± 0.1%1,3460%0.236
      30-Day mortality1,7311.0 ± 0.2%1,1720.7 ± 0.2%0.392
      Log-rank test.
      1-Year survival1,47798.4 ± 0.3%1,04699.1 ± 0.3%0.166
      Log-rank test.
      a Statistically significant results are shown in bold.
      b Log-rank test.

      Acute Versus Chronic Type B Aortic Dissection

      Overall complications (19.6 ± 1.4% vs. 12.3 ± 1.8%, P = 0.003), major complications (3.8 ± 0.6% vs. 1.6 ± 0.6%, P = 0.023), minor complications (16.7 ± 1.3% vs. 11.4 ± 1.8%, P = 0.024), and endovascular graft exclusion syndrome (5.7 ± 1.0% vs. 2.2 ± 0.7%, P = 0.008) increased significantly in patients undergoing stent-graft placement for acute AD compared with chronic AD patients (Appendix Table A3).

      Discussion

      This systematic review of 153 retrospective studies (7,901 patients) in China demonstrated that endovascular stent-graft placement is feasible and has a high technical success rate (>99%) for treating Stanford type B AD. In addition, the early, mid-term, and long-term survival rates after endovascular repair were approximately 99.0%, 98.1%, and 97.9%, respectively. The Investigation of Stent Grafts in Aortic Dissection trial reported that elective stent-graft placement in addition to optimal medical therapy (OMT) failed to improve the 1- and 2-year survival rates compared with OMT alone but did improve the 5-year survival rate for chronic uncomplicated type B AD.
      • Nienaber C.A.
      • Rousseau H.
      • Eggebrecht H.
      • et al.
      Randomized comparison of strategies for type B aortic dissection: the INvestigation of STEnt Grafts in Aortic Dissection (INSTEAD) trial.
      • Nienaber C.A.
      • Kische S.
      • Akin I.
      • et al.
      Strategies for subacute/chronic type B aortic dissection: the Investigation of Stent Grafts in Patients with type B Aortic Dissection (INSTEAD) trial 1-year outcome.
      • Nienaber C.A.
      • 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.
      Therefore, the survival rates after stent-graft placement appear to either compare favorably with those following medical therapy or at least suggest that the mortality rate following stent-graft placement does not increase. The International Registry of Acute Aortic Dissection (IRAD) study reported 3-year survival rates for patients treated medically, surgically, or with endovascular therapy of 77.6 ± 6.6%, 82.8 ± 18.9%, and 76.2 ± 25.2%, respectively (log-rank P = 0.61).
      • Tsai T.T.
      • Fattori R.
      • Trimarchi S.
      • et al.
      Long-term survival in patients presenting with type B acute aortic dissection: insights from the International Registry of Acute Aortic Dissection.
      However, the groups were not comparable because surgical or endovascular repair was only performed in patients with complicated AD, and OMT was used in uncomplicated AD cases. The survival rates at 1, 5, 10, and 15 years were 56%, 48%, 29%, and 11%, respectively, for acute type B AD treated surgically and 78%, 59%, 45%, and 27%, respectively, for chronic type B AD treated surgically.
      • Fann J.I.
      • Smith J.A.
      • Miller D.C.
      • et al.
      Surgical management of aortic dissection during a 30-year period.
      Another IRAD study revealed a 31.4% in-hospital mortality rate for acute type B AD treated surgically.
      • Hagan P.G.
      • Nienaber C.A.
      • Isselbacher E.M.
      • et al.
      The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease.
      In addition, 2 meta-analyses reported significantly lower 30-day mortality rates for acute type B AD treated with endovascular repair versus open surgery.
      • Luebke T.
      • Brunkwall J.
      Outcome of patients with open and endovascular repair in acute complicated type B aortic dissection: a systematic review and meta-analysis of case series and comparative studies.
      • Zhang H.
      • Wang Z.W.
      • Zhou Z.
      • et al.
      Endovascular stent-graft placement or open surgery for the treatment of acute type B aortic dissection: a meta-analysis.
      Although the early survival rates following stent-graft placement appear favorable compared with open surgery for elective cases of acute type B AD, conclusions must be interpreted cautiously in the absence of a randomized direct comparison with open surgery.
      Neurological complications, particularly paraplegia, are the most negative complications from surgical repair of type B AD. The IRAD investigators
      • Trimarchi S.
      • Nienaber C.A.
      • 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).
      reported neurological complications in 23.2% of patients treated surgically, with cerebrovascular accident and paraplegia occurring in 9.0% and 4.5% of patients, respectively. A study from the European Collaborators on Stent/Graft Techniques for Aortic Aneurysm Repair Registry
      • Buth J.
      • Harris P.L.
      • Hobo R.
      • et al.
      Neurologic complications associated with endovascular repair of thoracic aortic pathology: incidence and risk factors. A study from the European collaborators on Stent/graft techniques for aortic aneurysm repair (Eurostar) registry.
      reported lower paraplegia and stroke rates of 1.4% and 3.3%, respectively, for patients treated with endovascular repair. A meta-analysis indicated that endoluminal graft repair is accompanied by lower paraplegia rates (odds ratio [OR] 0.23, P = 0.005) compared with open repair.
      • Xenos E.S.
      • Minion D.J.
      • Davenport D.L.
      • et al.
      Endovascular versus open repair for descending thoracic aortic rupture: institutional experience and meta-analysis.
      Another meta-analysis indicated that paraplegia rates (OR = 0.256, P = 0.001) decreased significantly following endovascular repair compared with open repair.
      • Luebke T.
      • Brunkwall J.
      Outcome of patients with open and endovascular repair in acute complicated type B aortic dissection: a systematic review and meta-analysis of case series and comparative studies.
      Eggebrecht et al.
      • Eggebrecht H.
      • Nienaber C.A.
      • Neuhäuser M.
      • et al.
      Endovascular stent-graft placement in aortic dissection: a meta-analysis.
      observed overall neurological complications, stroke, and paraplegia in 2.9%, 1.9%, and 0.8% of patients treated with endovascular treatment, respectively. Our analysis revealed a significantly lower overall neurological complication rate of 1.3% of treated patients, including stroke in 0.8% of patients and paraplegia in 0.1%. The lower incidence of overall neurological complications may reflect the average age of the treated patients in our study, which was approximately 8 years younger than that reported by Eggebrecht et al.
      • Eggebrecht H.
      • Nienaber C.A.
      • Neuhäuser M.
      • et al.
      Endovascular stent-graft placement in aortic dissection: a meta-analysis.
      Elderly patients typically have more preexisting comorbidities, and advanced age is a well-known risk factor for advanced atherosclerosis. In addition, the number of female patients in our study was lower than that reported by Eggebrecht et al.
      • Eggebrecht H.
      • Nienaber C.A.
      • Neuhäuser M.
      • et al.
      Endovascular stent-graft placement in aortic dissection: a meta-analysis.
      (19.1% vs. 24.2%). Because female gender is associated with an increased stroke risk, the lower proportion of females in our population may have affected our estimates of stroke risk.
      • Buth J.
      • Harris P.L.
      • Hobo R.
      • et al.
      Neurologic complications associated with endovascular repair of thoracic aortic pathology: incidence and risk factors. A study from the European collaborators on Stent/graft techniques for aortic aneurysm repair (Eurostar) registry.
      In addition, the incidences of some risk factors, such as rupture dissection, were considerably reduced in our study compared with the study by Eggebrecht et al.
      • Eggebrecht H.
      • Nienaber C.A.
      • Neuhäuser M.
      • et al.
      Endovascular stent-graft placement in aortic dissection: a meta-analysis.
      (0.8 ± 0.1% vs. 16.1 ± 1.2%), thereby yielding more positive outcomes in our study. Finally, we observed a stent use of 1.1 stents per patient. A lower number of deployed stent grafts and a shorter length of aortic coverage can reduce the risk factors for paraplegia or stroke.
      • Buth J.
      • Harris P.L.
      • Hobo R.
      • et al.
      Neurologic complications associated with endovascular repair of thoracic aortic pathology: incidence and risk factors. A study from the European collaborators on Stent/graft techniques for aortic aneurysm repair (Eurostar) registry.
      • Amabile P.
      • Grisoli D.
      • Giorgi R.
      • et al.
      Incidence and determinants of spinal cord ischaemia in stent-graft repair of the thoracic aorta.
      Covering the left subclavian artery without revascularization increases the risk of paraplegia or stroke following an endoluminal repair of thoracic pathology.
      • Buth J.
      • Harris P.L.
      • Hobo R.
      • et al.
      Neurologic complications associated with endovascular repair of thoracic aortic pathology: incidence and risk factors. A study from the European collaborators on Stent/graft techniques for aortic aneurysm repair (Eurostar) registry.
      • Clough R.E.
      • Modarai B.
      • Topple J.A.
      • et al.
      Predictors of stroke and paraplegia in thoracic aortic endovascular intervention.
      • Feezor R.J.
      • Martin T.D.
      • Hess P.J.
      • et al.
      Risk factors for perioperative stroke during thoracic endovascular aortic repairs (TEVAR).
      Reconstruction of the left subclavian artery was not frequently performed, which might be one reason for the increase in neurological complications. Cerebrospinal fluid drainage is also routinely performed to prevent paraplegia if the aorta between T9 and T12 needs to be covered. Another option in China is a vascular occlude, which is a minimally invasive option that reduces the risk of ischemia of the spinal cord, liver, intestine, gallbladder, or kidney in the treatment of a distal re-entry tear in a patient with Stanford type B AD.
      • Tang X.
      • Fu W.
      • Xu X.
      • et al.
      Use of a vascular occluder to treat a re-entry tear in a patient with Stanford type B aortic dissection: acute and 1-year results.
      A case report described the use of a ventricular septal defect occlusion to treat a proximal entry tear in patients with chronic type B AD
      • Chang G.
      • Wang H.
      • Chen W.
      • et al.
      Endovascular repair of a type B aortic dissection with a ventricular septal defect occluder.
      ; however, the long-term results have not yet been published.
      Although the favorable survival and low rates of neurological complications in these initial experiences are encouraging, overall in-hospital complications occurred in 19.1% of the patients. Approximately 40% of these complications were procedure-related. Retrograde type A AD occurred in 0.1% and 0.4% of patients while in the hospital and during follow-up, respectively. Retrograde type A AD is attributable to a variety of causes, including a fragile aortic wall, disease progression, manipulation of guidewires/sheaths, and stent grafting–related factors.
      • Dong Z.H.
      • Fu W.G.
      • Wang Y.Q.
      • et al.
      Retrograde type A aortic dissection after endovascular stent graft placement for treatment of type B dissection.
      • Eggebrecht H.
      • Thompson M.
      • Rousseau H.
      • et al.
      Retrograde ascending aortic dissection during or after thoracic aortic stent graft placement: insight from the European registry on endovascular aortic repair complications.
      Therefore, careful patient selection, well-designed stent-graft devices, and standardized endovascular manipulation could prevent the occurrence of retrograde type A AD. Imaging surveillance after endovascular repair may enable the early detection of this life-threatening complication. Emerging AD and secondary endovascular procedures occurred in 0.3% and 1.1% of patients in our systematic review, respectively. As an adjunctive technique for endovascular repair, restrictive bare stents can reduce the incidence of stent graft–induced distal redissection and secondary intervention.
      • Feng J.
      • Lu Q.
      • Zhao Z.
      • et al.
      Restrictive bare stent for prevention of stent graft-induced distal redissection after thoracic endovascular aortic repair for type B aortic dissection.
      Our analysis suggests that centers with more experience had significantly greater 1-year survival rates and lower complication and 30-day mortality rates. Overall complication rates were lower in more recent studies compared with older studies. However, neurological complications increased. This increase may be due to 3 factors. First, there have been increases in the number of vascular centers capable of performing endovascular repair and the number of procedures that are performed. Second, there is some variation in operator training. Third, with the development of the technique and endograft technology, lumbar drainage or carotid subclavian bypass may be used less frequently in China. In addition, more challenging cases in terms of complexity are being diagnosed as the knowledge of doctors in local hospitals increases. Finally, the indication for endovascular repair has been expanded to high-risk patients who are more prone to complications. This expansion may underlie the broadening spectrum of acute and mid-term complications to include potentially life-threatening complications beyond paraplegia or stroke.
      • Eggebrecht H.
      • Baumgart D.
      • Radecke K.
      • et al.
      Aortoesophageal fistula secondary to stent-graft repair of the thoracic aorta.
      The technical revolution of stent grafts has steadily accelerated from the initial generation of distal straight stent grafts to the current generation of distal tapered stent grafts. Although stent grafts are designed to have a durability of 10 years based on International Organization for Standardization stress testing, their long-term durability is unknown. The earlier first-generation devices faced many problems (e.g., endoleaks, stent kinking, stent migration, retrograde type A AD, and aortic rupture). Before 2009, 60- to 130-mm stent grafts, which represent an oversizing of 10-30%, were used by the vast majority of doctors in China. These shorter stents did not conform to the shape of the junction between the aorta arch and the descending aorta. In addition, as techniques have improved, patients with complicated anatomical characteristics who do not meet the strict criteria for standard stent grafts can receive additional, fenestrated, branched, or chimney stent grafts. The excessive size of the older generation of stent grafts may lead to greater radial force against the aortic wall; therefore, an oversizing of 10–15% appears to be sufficient.
      • Dong Z.H.
      • Fu W.G.
      • Wang Y.Q.
      • et al.
      Retrograde type A aortic dissection after endovascular stent graft placement for treatment of type B dissection.
      Since 2009, an oversizing of 10–15%, corresponding to 150- to 240-mm stent grafts, has been used more frequently. The longer length and more suitable oversize selection in the new generation of stent grafts may provide controlled deployment and reduce potential aorta intimal injury and tears, which may consequently minimize the risks of endoleaks and retrograde type A AD.
      Regardless of whether first- or second-generation stents are used, endovascular repair is feasible with a high technical success rate. Our present study indicated that patients receiving second-generation stents seemed to have better outcomes. Nevertheless, the conclusions should be interpreted with caution because a younger average age may contribute to better outcomes for patients with second-generation stents to some extent. Furthermore, although stent graft–related complications have decreased in patients with second-generation stents, the postoperative and 5-year survival rates have not improved. Future well-designed stent grafts with more appropriate diameters and lengths may improve survival rates.
      Imaging studies were not routinely performed during follow-up. Eighty-two of the 153 studies did not describe changes in the morphology of the false lumens in detail after the procedure. Although 112, 104, 57, and 20 of the 153 studies reported 6-month, 1-year, 3-year and 5-year follow-up results, respectively, only 12, 11, and 1 studies reported specific 6-month, 1-year, and 2-year false lumen thrombosis values, respectively. Stent-graft placement failed to eliminate false lumen thrombosis in 6.8% of the patients. There was a risk of aortic rupture during follow-up in 1.2% of patients after endovascular repair, and adjunctive endovascular procedures and surgical conversion were required in approximately 3% of patients over time. Continued false lumen patency correlated strongly with late aneurysm formation; therefore, favorable remodeling is considered a surrogate to prevent late aneurysms.
      • Conrad M.F.
      • Crawford R.S.
      • Kwolek C.J.
      • et al.
      Aortic remodeling after endovascular repair of acute complicated type B aortic dissection.
      Several studies have demonstrated that endovascular repair can promote aortic remodeling.
      • Nienaber C.A.
      • Rousseau H.
      • Eggebrecht H.
      • et al.
      Randomized comparison of strategies for type B aortic dissection: the INvestigation of STEnt Grafts in Aortic Dissection (INSTEAD) trial.
      • 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.
      • Conrad M.F.
      • Crawford R.S.
      • Kwolek C.J.
      • et al.
      Aortic remodeling after endovascular repair of acute complicated type B aortic dissection.
      Another study demonstrated that thrombosis and remodeling of the false lumen can reduce late aneurysm formation and reintervention rates,
      • Brunkwall J.
      • Lammer J.
      • Verhoeven E.
      • et al.
      ADSORB: a study on the efficacy of endovascular grafting in uncomplicated acute dissection of the descending aorta.
      but the authors focused on technical success, potential benefits, and complications while ignoring changes in the morphology of the aorta during follow-up. Therefore, more thorough observations should be performed during follow-up to obtain more definitive data. In addition, the conclusions based on long-term results are unconvincing.
      The following limitations of the present systematic review must be considered. The main limitation is that all included studies were retrospective. The lack of random sequence generation and blinding tends to increase the risk of potential bias and may result in low representativeness. The relatively low percentage of studies for which data were available for some valuable parameters may have further increased the selection bias. In addition, the definitions and primary data were ambiguous in some articles, which may have decreased the reliability and limited the statistical power of this study. Some undetected duplicate and overlapping data that could not be identified may remain. Finally, imaging studies were not routinely performed during follow-up. Mid- and long-term (≥1 year) follow-up imaging information was not available for most included patients, which limited our ability to understand this critical end point. Therefore, the long-term outcomes of endovascular repair of type B AD remain unclear. The overall results and the number of stents utilized might reflect the increased number of younger patients with less complex dissections (6.1%) in our study (see page 28, Table I) compared with the study by Eggebrecht et al.,
      • Eggebrecht H.
      • Nienaber C.A.
      • Neuhäuser M.
      • et al.
      Endovascular stent-graft placement in aortic dissection: a meta-analysis.
      and therefore more positive early outcomes are noted in our study. The generalizability of these data might be limited to younger patients with less complex dissections.
      However, this systematic review was performed at an appropriate time because sufficient data have accumulated. We also applied multiple strategies to identify studies and used strict inclusion and exclusion criteria. Although this study did not compare stent grafts with other strategies for patients with type B AD, it provides important insights into the technical success, potential benefits, complications, stent evolution, and survival rates of endovascular stent-graft placement for type B AD.

      Conclusions

      In conclusion, endovascular stent-graft placement is feasible for treating Stanford type B AD and has a high technical success rate, favorable neurological complication rates, and high survival rates. Furthermore, the new generation of stent grafts appears to have favorable in-hospital and follow-up outcomes. However, although our methodology was rigorous, the inherent limitations of the included studies prevent the formation of definitive conclusions. Future well-designed RCTs from multiple centers with more thorough observation during follow-up are needed to confirm and update the findings of this analysis.
      This work was partially supported by grant no. 81070257 from the National Natural Science Foundation of China and grant no. 2013B021800121 from the Science and Technology Planning Project of Guangdong Province, China. The authors gratefully acknowledge Yilong Education for providing assistance with and advise on the statistical analysis.
      Role of the Funding Sources: The National Natural Science Foundation of China and the Science and Technology Planning Project of Guangdong Province, China, provided funding that was used to pay the editing and publication fees. The funding sources had no involvement in the study design; collection, analysis, and interpretation of data; writing of the report; or decision to submit the article for publication.

      Supplementary Data

      References

        • Svensson L.G.
        • Kouchoukos N.T.
        • Miller D.C.
        • et al.
        Expert consensus document on the treatment of descending thoracic aortic disease using endovascular stent-grafts.
        Ann Thorac Surg. 2008; 85: S1-S41
        • Fattori R.
        • Cao P.
        • De Rango P.
        • et al.
        Interdisciplinary expert consensus document on management of type B aortic dissection.
        J Am Coll Cardiol. 2013; 61: 1661-1678
        • Glower D.D.
        • Fann J.I.
        • Speier R.H.
        • et al.
        Comparison of medical and surgical therapy for uncomplicated descending aortic dissection.
        Circulation. 1990; 82: IV39-IV46
        • Nienaber C.A.
        • Rousseau H.
        • Eggebrecht H.
        • et al.
        Randomized comparison of strategies for type B aortic dissection: the INvestigation of STEnt Grafts in Aortic Dissection (INSTEAD) trial.
        Circulation. 2009; 120: 2519-2528
        • Nienaber C.A.
        • Kische S.
        • Akin I.
        • et al.
        Strategies for subacute/chronic type B aortic dissection: the Investigation of Stent Grafts in Patients with type B Aortic Dissection (INSTEAD) trial 1-year outcome.
        J Thorac Cardiovasc Surg. 2010; 140: S101-S108
        • Nienaber C.A.
        • 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 Intervent. 2013; 6: 407-416
        • Brunkwall J.
        • Lammer J.
        • Verhoeven E.
        • et al.
        ADSORB: a study on the efficacy of endovascular grafting in uncomplicated acute dissection of the descending aorta.
        Eur J Vasc Endovasc Surg. 2012; 44: 31-36
        • 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: 285-291
        • Luebke T.
        • Brunkwall J.
        Outcome of patients with open and endovascular repair in acute complicated type B aortic dissection: a systematic review and meta-analysis of case series and comparative studies.
        J Cardiovasc Surg (Torino). 2010; 51: 613-632
        • Xenos E.S.
        • Minion D.J.
        • Davenport D.L.
        • et al.
        Endovascular versus open repair for descending thoracic aortic rupture: institutional experience and meta-analysis.
        Eur J Cardiothorac Surg. 2009; 35: 282-286
        • Eggebrecht H.
        • Nienaber C.A.
        • Neuhäuser M.
        • et al.
        Endovascular stent-graft placement in aortic dissection: a meta-analysis.
        Eur Heart J. 2006; 27: 489-498
        • Tsai T.T.
        • Fattori R.
        • Trimarchi S.
        • et al.
        Long-term survival in patients presenting with type B acute aortic dissection: insights from the International Registry of Acute Aortic Dissection.
        Circulation. 2006; 114: 2226-2231
        • Fann J.I.
        • Smith J.A.
        • Miller D.C.
        • et al.
        Surgical management of aortic dissection during a 30-year period.
        Circulation. 1995; 92: 113-121
        • Hagan P.G.
        • Nienaber C.A.
        • Isselbacher E.M.
        • et al.
        The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease.
        JAMA. 2000; 283: 897-903
        • Zhang H.
        • Wang Z.W.
        • Zhou Z.
        • et al.
        Endovascular stent-graft placement or open surgery for the treatment of acute type B aortic dissection: a meta-analysis.
        Ann Vasc Surg. 2012; 26: 454-461
        • Trimarchi S.
        • Nienaber C.A.
        • 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: I357-I364
        • Buth J.
        • Harris P.L.
        • Hobo R.
        • et al.
        Neurologic complications associated with endovascular repair of thoracic aortic pathology: incidence and risk factors. A study from the European collaborators on Stent/graft techniques for aortic aneurysm repair (Eurostar) registry.
        J Vasc Surg. 2007; 46: 1103-1111
        • Amabile P.
        • Grisoli D.
        • Giorgi R.
        • et al.
        Incidence and determinants of spinal cord ischaemia in stent-graft repair of the thoracic aorta.
        Eur J Vasc Endovasc Surg. 2008; 35: 455-461
        • Clough R.E.
        • Modarai B.
        • Topple J.A.
        • et al.
        Predictors of stroke and paraplegia in thoracic aortic endovascular intervention.
        Eur J Vasc Endovasc Surg. 2011; 41: 303-310
        • Feezor R.J.
        • Martin T.D.
        • Hess P.J.
        • et al.
        Risk factors for perioperative stroke during thoracic endovascular aortic repairs (TEVAR).
        J Endovasc Ther. 2007; 14: 568-573
        • Tang X.
        • Fu W.
        • Xu X.
        • et al.
        Use of a vascular occluder to treat a re-entry tear in a patient with Stanford type B aortic dissection: acute and 1-year results.
        J Endovasc Ther. 2008; 15: 566-569
        • Chang G.
        • Wang H.
        • Chen W.
        • et al.
        Endovascular repair of a type B aortic dissection with a ventricular septal defect occluder.
        J Vasc Surg. 2010; 51: 1507-1509
        • Dong Z.H.
        • Fu W.G.
        • Wang Y.Q.
        • et al.
        Retrograde type A aortic dissection after endovascular stent graft placement for treatment of type B dissection.
        Circulation. 2009; 119: 735-741
        • Eggebrecht H.
        • Thompson M.
        • Rousseau H.
        • et al.
        Retrograde ascending aortic dissection during or after thoracic aortic stent graft placement: insight from the European registry on endovascular aortic repair complications.
        Circulation. 2009; 120: S276-S281
        • Feng J.
        • Lu Q.
        • Zhao Z.
        • et al.
        Restrictive bare stent for prevention of stent graft-induced distal redissection after thoracic endovascular aortic repair for type B aortic dissection.
        J Vasc Surg. 2013; 57: 44S-52S
        • Eggebrecht H.
        • Baumgart D.
        • Radecke K.
        • et al.
        Aortoesophageal fistula secondary to stent-graft repair of the thoracic aorta.
        J Endovasc Ther. 2004; 11: 161-167
        • Conrad M.F.
        • Crawford R.S.
        • Kwolek C.J.
        • et al.
        Aortic remodeling after endovascular repair of acute complicated type B aortic dissection.
        J Vasc Surg. 2009; 50: 510-517