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      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.

      The Journal of Thoracic and Cardiovascular Surgery
      Aged, Aneurysm, Dissecting, diagnosis, drug therapy, mortality, physiopathology, surgery, Aortic Aneurysm, Aortography, methods, Blood Pressure, Blood Vessel Prosthesis, Blood Vessel Prosthesis Implantation, adverse effects, instrumentation, Cardiovascular Agents, therapeutic use, Chi-Square Distribution, Chronic Disease, Combined Modality Therapy, Elective Surgical Procedures, Europe, Female, Humans, Kaplan-Meier Estimate, Magnetic Resonance Angiography, Male, Middle Aged, Prospective Studies, Risk Assessment, Risk Factors, Stents, Survival Rate, Time Factors, Tomography, X-Ray Computed, Treatment Outcome

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          Abstract

          Endovascular stent grafting represents a novel concept for type B aortic dissection both in the acute and subacute/chronic setting, with an unknown effect on outcomes. In a prospective trial 140 patients with stable type B dissection were randomly subjected to elective stent-graft placement in addition to optimal medical therapy (n = 72) or to optimal medical therapy (n = 68) with surveillance (arterial pressure according to World Health Organization guidelines ≤ 120/80 mm Hg). The primary end point was 1-year all-cause mortality, whereas aorta-related mortality, progression (with need for conversion or additional endovascular or open surgical intervention), and aortic remodeling were secondary end points. There was no difference in all-cause mortality: cumulative survival was 97.0% ± 3.4% with optimal medical therapy versus 91.3% ± 2.1% with thoracic endovascular aortic repair (P = .16). Moreover, aorta-related mortality was not different (P = .42), and the risk for the combined end point of aorta-related death (rupture) and progression (including conversion or additional endovascular or open surgical intervention) was similar (P = .86). Three neurologic adverse events occurred in the thoracic endovascular aortic repair group (1 paraplegia, 1 stroke, and 1 transient paraparesis) versus 1 episode of paraparesis with medical treatment. Finally, aortic remodeling (with true-lumen recovery and thoracic false-lumen thrombosis) occurred in 91.3% with thoracic endovascular aortic repair versus 19.4% with medical treatment (P < .001), which is suggestive of continued remodeling. In survivors of uncomplicated type B aortic dissection, elective stent-graft placement does not improve 1-year survival and adverse events, despite favorable aortic remodeling. Copyright © 2010 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.

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