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Bashir M, Jubouri M, Surkhi AO, Sadeghipour P, Pouraliakbar H, Rabiee P, Jolfayi AG, Mohebbi B, Moosavi J, Babaei M, Afrooghe A, Ghoorchian E, Awad WI, Velayudhan B, Mohammed I, Bailey DM, Williams IM. Aortic Arch Debranching and Thoracic Endovascular Aortic Repair (TEVAR) for Type B Aortic Dissection. Ann Vasc Surg 2024; 99:320-331. [PMID: 37866676 DOI: 10.1016/j.avsg.2023.08.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 08/12/2023] [Accepted: 08/28/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND Since its introduction, thoracic endovascular aortic repair (TEVAR) has revolutionized the treatment of type B aortic dissections (TBADs). However, the proximal aspect of the aortic pathology treated may infringe on the origin of the left subclavian artery or even more proximally. Hence, to ensure durable outcomes, the origin of these vessels needs to be covered, but an extra-anatomical bypass is required to perfuse vital branches, known as aortic arch debranching. This series aims to describe and delineate the disparities of aortic arch debranching during TEVAR for TBAD. METHODS A retrospective review and analysis of a multicenter international database was conducted to identify patients with TBAD treated with TEVAR between 2005 and 2021. Data analyzed included patient demographics, disease characteristics, operative characteristics, and postoperative outcomes with follow-up on mortality and reintervention. All statistical analyses were carried out using IBM SPSS 26. Patient survival was calculated using a Kaplan-Meier survival analysis, and a P value of less than 0.05 was considered statistically significant. RESULTS A total of 58 patients were included in the analysis, of which 27 (46.6%) presented with complicated disease and 31 were uncomplicated, of which 10 (17.2%) were classed as high risk and 21 (36.2%) low risk. Zone 2 was the most common proximal landing zone for the stent graft. Left subclavian artery bypass was performed selectively (26%), with 1 stroke occurring, likely due to embolic reasons. A further 6 underwent more proximal aortic debranching before TEVAR (10%) and was a significant risk factor for mortality and the number of stents deployed. The overall rates of reintervention and mortality were 17.2% (n = 10) and 29.3% (n = 17). CONCLUSIONS Aortic arch debranching and TEVAR for TBAD is associated with significant mortality. Future developments to treat aortic arch pathology could incorporate branched graft devices, eliminating the need for debranching, improving stroke rates, and reducing future reinterventions.
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Affiliation(s)
- Mohamad Bashir
- Vascular and Endovascular Surgery, Velindre University NHS Trust, Health Education and Improvement Wales (HEIW), Cardiff, UK.
| | - Matti Jubouri
- Hull York Medical School, University of York, York, UK
| | | | - Parham Sadeghipour
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Hamidreza Pouraliakbar
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Parham Rabiee
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Amir Ghaffari Jolfayi
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Bahram Mohebbi
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Jamal Moosavi
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammadreza Babaei
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Arya Afrooghe
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Ehsan Ghoorchian
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Wael I Awad
- Department of Cardiothoracic Surgery, Barts Heart Centre, St Bartholomew's Hospital, London, UK
| | - Bashi Velayudhan
- Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Science (SIMS Hospital), Chennai, Tamil Nadu, India
| | - Idhrees Mohammed
- Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Science (SIMS Hospital), Chennai, Tamil Nadu, India
| | - Damian M Bailey
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK
| | - Ian M Williams
- Department of Vascular Surgery, University Hospital of Wales, Cardiff, UK
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2
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Bashir M, Tan SZ, Jubouri M, Coselli J, Chen EP, Mohammed I, Velayudhan B, Sadeghipour P, Nienaber C, Awad WI, Slisatkorn W, Wong R, Piffaretti G, Mariscalco G, Bailey DM, Williams I. Uncomplicated Type B Aortic Dissection: Challenges in Diagnosis and Categorisation. Ann Vasc Surg 2023:S0890-5096(23)00223-6. [PMID: 37075834 DOI: 10.1016/j.avsg.2023.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 04/06/2023] [Accepted: 04/06/2023] [Indexed: 04/21/2023]
Abstract
BACKGROUND Acute type B aortic dissection (TBAD) is a rare disease that is likely under-diagnosed in the UK. As a progressive, dynamic clinical entity, many patients initially diagnosed with uncomplicated TBAD deteriorate, developing end-organ malperfusion and aortic rupture (complicated TBAD). An evaluation of the binary approach to the diagnosis and categorisation of TBAD is needed. METHODS A narrative review of the risk factors predisposing patients to progression from unTBAD to coTBAD was undertaken. RESULTS Key high-risk features predispose the development of complicated TBAD, such as maximal aortic diameter > 40 mm and partial false lumen thrombosis. CONCLUSION An appreciation of the factors that predispose to complicated TBAD would aid clinical decision-making surrounding TBAD.
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Affiliation(s)
- Mohamad Bashir
- Vascular and Endovascular Surgery, Health Education and Improvement Wales, Velindre University NHS Trust, Wales, UK.
| | - Sven Zcp Tan
- Barts and The London School of Medicine, Queen Mary University of London, UK
| | | | - Joseph Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University, Durham, North Carolina
| | - Idhrees Mohammed
- Institute of Cardiac and Aortic Disorders, SRM Institutes for Medical Sciences, SIMS Hospital, Chennai, India
| | - Bashi Velayudhan
- Institute of Cardiac and Aortic Disorders, SRM Institutes for Medical Sciences, SIMS Hospital, Chennai, India
| | - Parham Sadeghipour
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Christoph Nienaber
- Cardiology and Aortic Centre, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Wael I Awad
- Department of Cardiothoracic Surgery, Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Worawong Slisatkorn
- Division of Cardio-Thoracic Surgery, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Randolph Wong
- Department of Surgery, Division of Cardiothoracic Surgery, The Chinese University of Hong Kong, Hong Kong, People's Republic of China
| | - Gabrielle Piffaretti
- Vascular Surgery - Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
| | - Giovanni Mariscalco
- Department of Cardiac Surgery, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Damian M Bailey
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, UK
| | - Ian Williams
- Department of Vascular Surgery, University Hospital of Wales, Cardiff, UK
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3
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Inter-observer variability of expert-derived morphologic risk predictors in aortic dissection. Eur Radiol 2023; 33:1102-1111. [PMID: 36029344 PMCID: PMC10017115 DOI: 10.1007/s00330-022-09056-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 07/20/2022] [Accepted: 07/24/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVES Establishing the reproducibility of expert-derived measurements on CTA exams of aortic dissection is clinically important and paramount for ground-truth determination for machine learning. METHODS Four independent observers retrospectively evaluated CTA exams of 72 patients with uncomplicated Stanford type B aortic dissection and assessed the reproducibility of a recently proposed combination of four morphologic risk predictors (maximum aortic diameter, false lumen circumferential angle, false lumen outflow, and intercostal arteries). For the first inter-observer variability assessment, 47 CTA scans from one aortic center were evaluated by expert-observer 1 in an unconstrained clinical assessment without a standardized workflow and compared to a composite of three expert-observers (observers 2-4) using a standardized workflow. A second inter-observer variability assessment on 30 out of the 47 CTA scans compared observers 3 and 4 with a constrained, standardized workflow. A third inter-observer variability assessment was done after specialized training and tested between observers 3 and 4 in an external population of 25 CTA scans. Inter-observer agreement was assessed with intraclass correlation coefficients (ICCs) and Bland-Altman plots. RESULTS Pre-training ICCs of the four morphologic features ranged from 0.04 (-0.05 to 0.13) to 0.68 (0.49-0.81) between observer 1 and observers 2-4 and from 0.50 (0.32-0.69) to 0.89 (0.78-0.95) between observers 3 and 4. ICCs improved after training ranging from 0.69 (0.52-0.87) to 0.97 (0.94-0.99), and Bland-Altman analysis showed decreased bias and limits of agreement. CONCLUSIONS Manual morphologic feature measurements on CTA images can be optimized resulting in improved inter-observer reliability. This is essential for robust ground-truth determination for machine learning models. KEY POINTS • Clinical fashion manual measurements of aortic CTA imaging features showed poor inter-observer reproducibility. • A standardized workflow with standardized training resulted in substantial improvements with excellent inter-observer reproducibility. • Robust ground truth labels obtained manually with excellent inter-observer reproducibility are key to develop reliable machine learning models.
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4
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Jafarinia A, Melito GM, Müller TS, Rolf-Pissarczyk M, Holzapfel GA, Brenn G, Ellermann K, Hochrainer T. Morphological parameters affecting false lumen thrombosis following type B aortic dissection: a systematic study based on simulations of idealized models. Biomech Model Mechanobiol 2023; 22:885-904. [PMID: 36630014 PMCID: PMC10167197 DOI: 10.1007/s10237-023-01687-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 01/02/2023] [Indexed: 01/12/2023]
Abstract
Type B aortic dissection (TBAD) carries a high risk of complications, particularly with a partially thrombosed or patent false lumen (FL). Therefore, uncovering the risk factors leading to FL thrombosis is crucial to identify high-risk patients. Although studies have shown that morphological parameters of the dissected aorta are related to FL thrombosis, often conflicting results have been reported. We show that recent models of thrombus evolution in combination with sensitivity analysis methods can provide valuable insights into how combinations of morphological parameters affect the prospect of FL thrombosis. Based on clinical data, an idealized geometry of a TBAD is generated and parameterized. After implementing the thrombus model in computational fluid dynamics simulations, a global sensitivity analysis for selected morphological parameters is performed. We then introduce dimensionless morphological parameters to scale the results to individual patients. The sensitivity analysis demonstrates that the most sensitive parameters influencing FL thrombosis are the FL diameter and the size and location of intimal tears. A higher risk of partial thrombosis is observed when the FL diameter is larger than the true lumen diameter. Reducing the ratio of the distal to proximal tear size increases the risk of FL patency. In summary, these parameters play a dominant role in classifying morphologies into patent, partially thrombosed, and fully thrombosed FL. In this study, we point out the predictive role of morphological parameters for FL thrombosis in TBAD and show that the results are in good agreement with available clinical studies.
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Affiliation(s)
- Alireza Jafarinia
- Institute of Strength of Materials, Graz University of Technology, Graz, Austria.
| | - Gian Marco Melito
- Institute of Mechanics, Graz University of Technology, Graz, Austria.
| | - Thomas Stephan Müller
- Institute of Fluid Mechanics and Heat Transfer, Graz University of Technology, Graz, Austria
| | | | - Gerhard A Holzapfel
- Institute of Biomechanics, Graz University of Technology, Graz, Austria.,Department of Structural Engineering, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Günter Brenn
- Institute of Fluid Mechanics and Heat Transfer, Graz University of Technology, Graz, Austria
| | - Katrin Ellermann
- Institute of Mechanics, Graz University of Technology, Graz, Austria
| | - Thomas Hochrainer
- Institute of Strength of Materials, Graz University of Technology, Graz, Austria
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5
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Oberhuber A, Raddatz A, Betge S, Ploenes C, Ito W, Janosi RA, Ott C, Langheim E, Czerny M, Puls R, Maßmann A, Zeyer K, Schelzig H. Interdisciplinary German clinical practice guidelines on the management of type B aortic dissection. GEFASSCHIRURGIE 2023; 28:1-28. [PMCID: PMC10123596 DOI: 10.1007/s00772-023-00995-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/14/2023] [Indexed: 08/13/2023]
Affiliation(s)
- A. Oberhuber
- German Society of Vascular Surgery and Vascular Medicine (DGG); Department of Vascular and Endovascular Surgery, University Hospital of Münster, Münster, Germany
| | - A. Raddatz
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI); Department of Anaesthesiology, Critical Care and Pain Medicine, Saarland University Hospital, Homburg, Germany
| | - S. Betge
- German Society of Angiology and Vascular Medicine (DGG); Department of Internal Medicine and Angiology, Helios Hospital Salzgitter, Salzgitter, Germany
| | - C. Ploenes
- German Society of Geriatrics (DGG); Department of Angiology, Schön Klinik Düsseldorf, Düsseldorf, Germany
| | - W. Ito
- German Society of Internal Medicine (GSIM) (DGIM); cardiovascular center Oberallgäu Kempten, Hospital Kempten, Kempten, Germany
| | - R. A. Janosi
- German Cardiac Society (DGK); Department of Cardiology and Angiology, University Hospital Essen, Essen, Germany
| | - C. Ott
- German Society of Nephrology (DGfN); Department of Nephrology and Hypertension, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
- Department of Nephrology and Hypertension, Paracelsus Medical University, Nürnberg, Germany
| | - E. Langheim
- German Society of prevention and rehabilitation of cardiovascular diseaese (DGPR), Reha Center Seehof, Teltow, Germany
| | - M. Czerny
- German Society of Thoracic and Cardiovascular Surgery (DGTHG), Department University Heart Center Freiburg – Bad Krozingen, Freiburg, Germany
- Albert Ludwigs University Freiburg, Freiburg, Germany
| | - R. Puls
- German Radiologic Society (DRG); Institute of Diagnostic an Interventional Radiology and Neuroradiology, Helios Klinikum Erfurt, Erfurt, Germany
| | - A. Maßmann
- German Society of Interventional Radiology (DeGIR); Department of Diagnostic an Interventional Radiology, Saarland University Hospital, Homburg, Germany
| | - K. Zeyer
- Marfanhilfe e. V., Weiden, Germany
| | - H. Schelzig
- German Society of Surgery (DGCH); Department of Vascular and Endovascular Surgery, University Hospital of Düsseldorf, Düsseldorf, Germany
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6
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Wu J, Wu Y, Li F, Zhuang D, Cheng Y, Chen Z, Yang J, Liu J, Li X, Fan R, Sun T. Natural history of isolated abdominal aortic dissection: A prospective cohort study. Front Cardiovasc Med 2023; 10:1002832. [PMID: 36910543 PMCID: PMC9996307 DOI: 10.3389/fcvm.2023.1002832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 01/31/2023] [Indexed: 02/25/2023] Open
Abstract
Objectives Isolated abdominal aortic dissection (IAAD) is extremely rare, with its optimal treatment and intervention timing remaining poorly understood. We aimed to study the natural history of IAAD and facilitate better clinical decision. Methods Consecutive patients admitted to our institution from January 2016 to April 2021 were enrolled and followed up prospectively. All-cause death was taken as the primary endpoint. Results A total of 68 patients with IAAD were included. The mean age at presentation was 61.2 ± 14.8 (Range: 26.0, 93.0) years and 55 (80.9%) were male. A total of 38 (55.9%) patients were treated conservatively, 27 (39.7%) received endovascular aneurysm repair (EVAR), and 3 (4.4%) underwent open surgery. After a mean follow-up of 2.4 years (Range: 0.1, 5.5), 9 (13.2%) patients died, 8 of whom (21.0%) were treated conservatively and 1 EVAR (3.7%). Compared with EVAR/open surgery, patient treated conservatively had a much worse survival (p = 0.043). There was no significant difference between different IAAD aortic sizes regarding mortality (p = 0.220). Patients with completely thrombosed false lumen fared improved survival rate, followed by partial thrombosis and patency, respectively, although not significantly (p = 0.190). No significant difference was observed between male and female concerning survival rate (p = 0.970). Patients without symptoms had a significantly improved survival (p = 0.048). Conclusion On the basis of patients' preference and surgeons' experience, a more aggressive treatment regimen for IAAD should be considered, with EVAR being the first choice, especially for those with persistent symptoms and patent false lumen, regardless of sex, age, or aortic size.
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Affiliation(s)
- Jinlin Wu
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yanfen Wu
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Fei Li
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Donglin Zhuang
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yunqing Cheng
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Zerui Chen
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jue Yang
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jie Liu
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Xin Li
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Ruixin Fan
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Tucheng Sun
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
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7
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Bashir M, Jubouri M, Tan SZCP, Bailey DM, Velayudhan B, Mohammed I, Wong RHL, Czerny M, Chen EP, Girardi LN, Coselli JS, Williams I. The misnomer of uncomplicated type B aortic dissection. J Card Surg 2022; 37:2761-2765. [PMID: 35775745 DOI: 10.1111/jocs.16728] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 04/01/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND Acute type B aortic dissection (TBAD) is a rare condition that can be divided into complicated (CoTBAD) and uncomplicated (UnCoTBAD) based on certain presenting clinical and radiological features, with UnCoTBAD constituting the majority of TBAD cases. The classification of TBAD directly affects the treatment pathway taken, however, there remains confusion as to exactly what differentiates complicated from uncomplicated TBAD. AIMS The scope of this review is to delineate the literature defining the intervention parameters for UnCoTBAD. METHODS A comprehensive literature search was conducted using multiple electronic databases including PubMed, Scopus, and EMBASE to collate and summarize all research evidence on intervention parameters and protocols for UnCoTBAD. RESULTS A TBAD without evidence of malperfusion or rupture might be classified as uncomplicated but there remains a subgroup who might exhibit high-risk features. Two clinical features representative of "high risk" are refractory pain and persistent hypertension. First-line treatment for CoTBAD is TEVAR, and whilst this has also proven its safety and effectiveness in UnCoTBAD, it is still being managed conservatively. However, TBAD is a dynamic pathology and a significant proportion of UnCoTBADs can progress to become complicated, thus necessitating more complex intervention. While the "high-risk" UnCoTBAD do benefit the most from TEVAR, yet, the defining parameters are still debatable as this benefit can be extended to a wider UnCoTBAD population. CONCLUSION Uncomplicated TBAD remains a misnomer as it is frequently representative of a complex ongoing disease process requiring very close monitoring in a critical care setting. A clear diagnostic pathway may improve decision making following a diagnosis of UnCoTBAD. Choice of treatment still predominantly depends on when an equilibrium might be reached where the risks of TEVAR outweigh the natural history of the dissection in both the short- and long-term.
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Affiliation(s)
- Mohamad Bashir
- Vascular & Endovascular Surgery, Velindre University NHS Trust, Health Education & Improvement Wales (HEIW), Cardiff, UK.,Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Science (SIMS Hospital), Chennai, Tamil Nadu, India
| | - Matti Jubouri
- Hull York Medical School, University of York, New York, UK
| | - Sven Z C P Tan
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Damian M Bailey
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK
| | - Bashi Velayudhan
- Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Science (SIMS Hospital), Chennai, Tamil Nadu, India
| | - Idhrees Mohammed
- Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Science (SIMS Hospital), Chennai, Tamil Nadu, India
| | - Randolph H L Wong
- Department of Surgery, Division of Cardiothoracic Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Martin Czerny
- Department of Cardiovascular Surgery, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, University Heart Center Freiburg, Freiburg, Germany
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA.,Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas, USA.,CHI St Luke's-Baylor St. Luke's Medical Center, Houston, Texas, USA
| | - Ian Williams
- Department of Vascular Surgery, University Hospital of Wales, Cardiff, UK
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8
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Wu J, Song J, Li X, Yang J, Yu C, Zhou C, Sun T, Fan R. Is Partially Thrombosed False Lumen Really a Predictor for Adverse Events in Uncomplicated Type B Aortic Dissection: A Systematic Review and Meta-Analysis? Front Cardiovasc Med 2022; 8:788541. [PMID: 35118140 PMCID: PMC8804284 DOI: 10.3389/fcvm.2021.788541] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Accepted: 12/28/2021] [Indexed: 12/22/2022] Open
Abstract
Objective:This meta-analysis and systematic review investigated whether partial thrombosed false lumen was a predictor for adverse events in uncomplicated Type B aortic dissection (TBAD).Methods:We performed the current systematic review of the medical literature according to the 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The Newcastle-Ottawa Scale was used to evaluate the quality of individual studies. Search terms based on the MEDLINE database included “type B aortic dissection,” “false lumen” and “thrombosis.” The primary outcomes included mortality, intervention, and aortic growth.Results:Six studies were included in this systematic review, with a total number of 692 patients, including 197 patency (28.5%), 214 partial thrombosis (30.9%), and 281 complete thrombosis (40.6%). Due to the insufficient data for quantitative analysis, we only conducted a scoping review for mortality and intervention. For aortic growth, we conducted a meta-analysis based on Standardized Mean Difference (SMD). The SMD of PT vs. P by random effect model was −0.05 (random effect model) [95% confidence interval (CI), −0.39 to 0.29]. The 95% CI crossed with the null line of 0, indicating no significant difference. The SMD was 0.37 (fixed effects model) (95% CI, 0.03–0.71) and 0.70 (fixed effects model) (95% CI, 0.37–1.04) for PT vs. CT, and P vs. CT, respectively.Conclusions:Current researches on partial thrombosis of TBAD are inconsistent. Partial thrombosis is not associated with a faster aortic growth rate. Until more solid evidence is available, we do not recommend partial thrombosis as a surgical indication or high-risk profile for TBAD.Systematic Review Registration: Unique Identifier: CRD42019121912.
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Affiliation(s)
- Jinlin Wu
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- *Correspondence: Jinlin Wu
| | - Jian Song
- Department of Vascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xin Li
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jue Yang
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Changjiang Yu
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Chenyu Zhou
- Department of Vascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Tucheng Sun
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Tucheng Sun
| | - Ruixin Fan
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Ruixin Fan
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9
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Zhang J, Zhang Z, Fu L, Wang L, Yang Y, Wang H, Zhou B, Wang W, Zhang J, Xin S. Obstructive Sleep Apnoea in Stanford Type B Aortic Dissection Is Associated With Multiple Imaging Signs Related to Late Aortic Events. Front Cardiovasc Med 2021; 8:752763. [PMID: 34869658 PMCID: PMC8636812 DOI: 10.3389/fcvm.2021.752763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 10/25/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Obstructive sleep apnoea (OSA) is highly prevalent in patients with Stanford type B aortic dissection (TBAD). Few studies have evaluated the effects of OSA on vascular changes in TBAD patients. This study aimed to explore the effect of OSA on aortic morphological changes in TBAD patients and its relation to late aortic events (LAEs). Methods: This case-control study included 143 TBAD patients. The diameters of different parts of the aorta were measured based on computed tomography angiography (CTA). According to the apnoea-hypopnoea index (AHI), OSA was classified as mild (5 ≤ AHI ≤ 15), moderate (15 < AHI ≤ 30), or severe (AHI > 30). The false lumen (FL) status was evaluated and classified as partially thrombosed, patent, or completely thrombosed. Results: The OSA prevalence in TBAD patients was 64.3%, and image differences related to LAEs between TBAD patients with and without OSA included the maximum aortic diameter at onset (37.3 ± 3.9 vs. 40.3 ± 4.5 mm, p < 0.001), the FL diameter of the proximal descending thoracic aorta (16.0 ± 6.8 vs. 20.3 ± 4.7 mm, p < 0.001), and the proportion of the FL that was partially thrombosed (39.2 vs. 64.1%, p = 0.004). Additionally, in the multivariable analysis of patients with OSA, the risks of an aortic diameter ≥40 mm, a proximal descending aorta FL ≥ 22 mm and a partially thrombosed FL were 4.611 (95% CI: 1.796–11.838, p = 0.001), 2.544 (95% CI: 1.050–6.165, p = 0.039), and 2.565 (95% CI: 1.167–5.637, p = 0.019), respectively, after adjustment for confounding factors. Trend tests showed that the risks of an aortic diameter ≥40 mm and a partially thrombosed FL increased with increasing OSA severity. Conclusions: TBAD patients with moderate to severe OSA have aortic dilatation in different parts of the aorta. OSA is an independent risk factor for multiple imaging signs related to LAEs, suggesting that OSA is an important factor affecting the prognosis of TBAD patients.
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Affiliation(s)
- Jiawei Zhang
- Department of Vascular Surgery, The First Hospital of China Medical University, Shenyang, China
| | - Zhe Zhang
- Department of Vascular Surgery, The First Hospital of China Medical University, Shenyang, China
| | - Lingyu Fu
- Department of Clinical Epidemiology and Evidence Medicine, The First Hospital of China Medical University, Shenyang, China
| | - Lei Wang
- Department of Vascular Surgery, The First Hospital of China Medical University, Shenyang, China
| | - Yu Yang
- Department of Vascular Surgery, The First Hospital of China Medical University, Shenyang, China
| | - Hao Wang
- Department of Vascular Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Baosen Zhou
- Department of Clinical Epidemiology and Evidence Medicine, The First Hospital of China Medical University, Shenyang, China
| | - Wei Wang
- Department of Respiratory Medicine, The First Hospital of China Medical University, Shenyang, China
| | - Jian Zhang
- Department of Vascular Surgery, The First Hospital of China Medical University, Shenyang, China
| | - Shijie Xin
- Department of Vascular Surgery, The First Hospital of China Medical University, Shenyang, China
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10
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Nugraha RA, Amshar M, Batubara EAD, Siddiq T, Indriani S, Adiarto S. Descending Aorta Diameters as Predictor of Late Adverse Outcomes in Patients with Uncomplicated Type B Aortic Dissection: A Systematic Review and Meta-Analysis. Ann Vasc Surg 2021; 80:333-344. [PMID: 34780948 DOI: 10.1016/j.avsg.2021.10.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 10/04/2021] [Accepted: 10/04/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND A subset of patients with uncomplicated type B aortic dissection (uTBAD) has been shown to possess higher risk of experiencing late adverse outcomes. Therefore, we conducted an analysis to investigate the role of descending aorta diameters, including total descending aorta diameter and false lumen diameter, as predictor of late adverse outcomes in patients with uTBAD. METHODS A systematic search was performed through Pubmed, ClinicalKey, ScienceDirect, and Cochrane Library to identify relevant studies. Our primary outcome was the composite late adverse events following their first episode of hospitalization. All meta-analyses were performed using Review Manager version 5.4. RESULTS A total of 2,339 (male 68.8%) patients from a total of 15 cohorts were included in our analysis. During follow-up period, there were 655 (27.3%) and 149 (6.3%) cases of late adverse events and mortality, respectively. Patients with higher initial descending aorta diameter were at higher risk of developing late adverse events (RR 2.99 [2.60, 3.44]; P < 0.001) and mortality (RR 3.15 [2.34, 4.25]; P <0.001) throughout follow-up period. Maximum false lumen diameter at the initial presentation seemed to significantly be associated with late adverse events (RR 1.87 [1.46, 2.39]; P <0.001) but not with mortality (RR 2.55 [0.81-8.00; P = 0.11). CONCLUSION Descending aorta diameters, particularly maximum initial descending aorta diameter, is a good and helpful predictor of late adverse outcomes in patients with uTBAD.
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Affiliation(s)
- Raka Aldy Nugraha
- Department of General Medicine, Universitas Indonesia Hospital, Depok, West Java, Indonesia.
| | - Mohamed Amshar
- Department of General Medicine, Universitas Indonesia Hospital, Depok, West Java, Indonesia
| | | | - Taofan Siddiq
- Department of Cardiology and Vascular Medicine, Faculty of Medicine Universitas Indonesia/National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
| | - Suci Indriani
- Department of Cardiology and Vascular Medicine, Faculty of Medicine Universitas Indonesia/National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
| | - Suko Adiarto
- Department of Cardiology and Vascular Medicine, Faculty of Medicine Universitas Indonesia/National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
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11
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Romeiro AB, Nogueira C, Coelho A, Mansilha A. Predictors of adverse events in uncomplicated type B aortic dissection: a systematic review with meta-analysis. INT ANGIOL 2021; 40:416-424. [PMID: 34236152 DOI: 10.23736/s0392-9590.21.04687-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Thoracic Endovascular Aortic Repair (TEVAR) has been selectively used for uncomplicated acute type B Aortic Dissection (TBAD); however, not all cases will benefit from TEVAR. A search for high risk clinical and radiographic predictors for complications is ongoing. This systematic review and meta-analysis aimed to identify predictors of major adverse events during follow-up of uncomplicated TBAD, in order to identify who might benefit from elective TEVAR. EVIDENCE ACQUISITION A systematic review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-analysis (PRISMA) statement. EVIDENCE SYNTHESIS 16 studies were included in a qualitative synthesis and 10 in the meta-analysis. Several risk factors associated to major adverse events have been described, including (1) aortic diameter ≥40 mm, (2) greater false lumen diameter (>22mm), (3) patent false lumen, (4) primary entry tear > 10mm, and (5) greater number of false lumen vessels origin. Quantitative synthesis identified an aortic diameter ≥40 mm significantly associated with major adverse events (HR=3.56; p<0.00001). Reporting of false lumen status, aortic diameters and growth, and demographic data was not always congruent with the most recent recommendations by Society for Vascular Surgery and Society of Thoracic Surgeons, published in 2020. CONCLUSIONS Acute and subacute patients with uncomplicated TBAD presenting with an aortic diameter ≥ 40 mm and solely treated with BMT have an increased hazard of developing major adverse events (HR), making them potential candidates for TEVAR. Remaining risk factors analysed have weaker evidence.
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Affiliation(s)
- Ana B Romeiro
- Faculty of Medicine, University of Porto, Porto, Portugal -
| | - Clara Nogueira
- Faculty of Medicine, University of Porto, Porto, Portugal.,Department of Angiology and Vascular Surgery, Centro Hospitalar Vila Nova de Gaia/ Espinho, Vila Nova de Gaia, Portugal
| | - Andreia Coelho
- Faculty of Medicine, University of Porto, Porto, Portugal.,Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Armando Mansilha
- Faculty of Medicine, University of Porto, Porto, Portugal.,Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal
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12
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Murillo H, Molvin L, Chin AS, Fleischmann D. Aortic Dissection and Other Acute Aortic Syndromes: Diagnostic Imaging Findings from Acute to Chronic Longitudinal Progression. Radiographics 2021; 41:425-446. [PMID: 33646901 DOI: 10.1148/rg.2021200138] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Acute aortic dissection is the prototype of acute aortic syndromes (AASs), which include intramural hematoma, limited intimal tear, penetrating atherosclerotic ulcer, traumatic or iatrogenic aortic dissection, and leaking or ruptured aortic aneurysm. The manifestation is usually sudden and catastrophic with acutely severe tearing chest or back pain. However, clinical symptoms do not allow distinction between AAS types and other acute pathologic conditions. Diagnostic imaging is essential to rapidly confirm and accurately diagnose the type, magnitude, and complications of AASs. CT fast acquisition of volumetric datasets has become instrumental in diagnosis, surveillance, and intervention planning. Most critical findings affecting initial intervention and prognosis are obtained at CT, including involvement of the ascending aorta, primary intimal tear location, rupture, malperfusion, size and patency of the false lumen, complexity and extent of the dissection, maximum caliber of the aorta, and progression or postintervention complications. Involvement of the ascending aorta-Stanford type A-has the most rapid lethal complications and requires surgical intervention to affect its morbidity and mortality. Lesions not involving the ascending aorta-Stanford type B-have a lesser rate of complications in the acute phase. During the acute to longitudinal progression, various specific and nonspecific imaging findings are encountered, including pleural and pericardial effusions, fluid collections, progression including aortic enlargement, and postoperative changes that can be discerned at CT. A systematic analysis algorithm is proposed for CT of the entire aorta throughout the continuum of AASs into the chronic and posttreated disease state, which synthesizes and communicates salient findings to all care providers. Online supplemental material is available for this article. ©RSNA, 2021.
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Affiliation(s)
- Horacio Murillo
- From the Department of Radiology, Enloe Medical Center, 1531 Esplanade, Chico, CA 95926 (H.M.); Department of Radiology, Stanford University School of Medicine, Stanford, Calif (L.M., D.F.); and Department of Radiology, Centre Hospitalier de l'Université de Montréal, Montréal, Quebec, Canada (A.S.C.)
| | - Lior Molvin
- From the Department of Radiology, Enloe Medical Center, 1531 Esplanade, Chico, CA 95926 (H.M.); Department of Radiology, Stanford University School of Medicine, Stanford, Calif (L.M., D.F.); and Department of Radiology, Centre Hospitalier de l'Université de Montréal, Montréal, Quebec, Canada (A.S.C.)
| | - Anne S Chin
- From the Department of Radiology, Enloe Medical Center, 1531 Esplanade, Chico, CA 95926 (H.M.); Department of Radiology, Stanford University School of Medicine, Stanford, Calif (L.M., D.F.); and Department of Radiology, Centre Hospitalier de l'Université de Montréal, Montréal, Quebec, Canada (A.S.C.)
| | - Dominik Fleischmann
- From the Department of Radiology, Enloe Medical Center, 1531 Esplanade, Chico, CA 95926 (H.M.); Department of Radiology, Stanford University School of Medicine, Stanford, Calif (L.M., D.F.); and Department of Radiology, Centre Hospitalier de l'Université de Montréal, Montréal, Quebec, Canada (A.S.C.)
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13
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Richter GM. State-of-the-Art Imaging of the Aorta with Respect to Endoluminal Intervention. Cardiovasc Intervent Radiol 2020; 43:1745-1755. [DOI: 10.1007/s00270-020-02680-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 10/05/2020] [Indexed: 01/16/2023]
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14
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Kazimierczak A, Rynio P, Jędrzejczak T, Samad R, Rybicka A, Gutowski P. Aortic Remodeling After Extended PETTICOAT Technique in Acute Aortic Dissection Type III B. Ann Vasc Surg 2020; 66:183-192. [DOI: 10.1016/j.avsg.2019.10.056] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Revised: 09/25/2019] [Accepted: 10/05/2019] [Indexed: 11/30/2022]
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15
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Commentary: Risk of aortic intervention after type B dissection—You cannot win unless you keep score. J Thorac Cardiovasc Surg 2020; 159:2187-2188. [DOI: 10.1016/j.jtcvs.2019.08.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Accepted: 08/05/2019] [Indexed: 11/20/2022]
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16
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Hossack M, Patel S, Gambardella I, Neequaye S, Antoniou GA, Torella F. Endovascular vs. Medical Management for Uncomplicated Acute and Sub-acute Type B Aortic Dissection: A Meta-analysis. Eur J Vasc Endovasc Surg 2020; 59:794-807. [DOI: 10.1016/j.ejvs.2019.08.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 07/07/2019] [Accepted: 08/02/2019] [Indexed: 12/29/2022]
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17
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Omura A, Matsuda H, Fukuda T, Nomura Y, Kawasaki R, Murakami H, Yamada A, Gan K, Mukohara N, Kobayashi J. Midterm outcomes of thoracic endovascular repair for uncomplicated type B aortic dissection with double-barrel type. Gen Thorac Cardiovasc Surg 2019; 67:1021-1029. [DOI: 10.1007/s11748-019-01128-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Accepted: 04/21/2019] [Indexed: 10/26/2022]
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18
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Ramdon A, Darling RC. Acute Type B Dissection. VASCULAR AND ENDOVASCULAR REVIEW 2019. [DOI: 10.15420/ver.2018.21.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Aortic dissections are catastrophic vascular emergencies, and early recognition and appropriate interventions can be crucial to survival. Research has changed the way aortic dissections are managed over the past two decades and will continue to contribute to the evolution of treatment modalities. Early treatment for uncomplicated type B dissections still remains controversial but certain characteristics may benefit from early intervention.
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Affiliation(s)
- Andre Ramdon
- Albany Medical College/Albany Medical Center Hospital, Albany, NY, US
| | - R Clement Darling
- Albany Medical College/Albany Medical Center Hospital, Albany, NY, US; Division of Vascular Surgery, Albany Medical Center Hospital, Albany, NY, US
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19
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Taylor AP, Freeman RV, Bartek MA, Shalhub S. Left ventricular hypertrophy is a possible biomarker for early mortality after type B aortic dissection. J Vasc Surg 2018; 69:1710-1718. [PMID: 30552040 DOI: 10.1016/j.jvs.2018.09.050] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 09/26/2018] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Data regarding the cardiac abnormalities associated with Stanford type B aortic dissection (TBAD) and whether these abnormalities are related to outcomes are limited. We describe the prevalence of cardiac abnormalities in patients with TBAD as detected by echocardiography. METHODS This retrospective review included patients with TBAD presenting between 1990 and 2016. Echocardiograms performed within 6 weeks of acute TBAD were reviewed. Cardiac function, valve abnormalities, and stigmata of hypertensive heart disease including left ventricular hypertrophy (LVH) were ascertained. Characteristics of patients who did and did not receive echocardiograms were compared. Outcomes of patients with and without evidence of LVH on echocardiography were also compared. RESULTS Of 239 patients with TBAD, 90 had echocardiograms performed within 6 weeks of acute TBAD (74% male; mean age, 57.8 ± 13.2 years). Echocardiograms were obtained at a median of 2 days (range, 0-41 days) from acute TBAD. Patients who had echocardiograms were more likely to present with malperfusion (28% vs 14%; P < .01) and had a trend toward increased operative repair during the subacute phase (17.4% vs 9.5%; P = .07) compared with patients who did not receive an echocardiogram. A majority of patients (57%) had at least mild LVH, including 39% of patients without a prior diagnosis of hypertension. Fibrocalcific changes associated with hypertension, including aortic sclerosis and mitral annular calcification, were noted in 40% and 11% of the patients, respectively. Among patients with LVH, there was a trend toward higher all-cause mortality (35% vs 23%; P = .21) and a younger age at death (58 ± 14 years vs 66 ± 13 years; P = .19) despite a similar age at TBAD onset. In a multivariable analysis controlling for age, sex, and admission estimated glomerular filtration rate, LVH independently predicted all-cause mortality (hazard ratio, 2.38; 95% confidence interval, 1.02-5.56; P = .04). CONCLUSIONS LVH and other findings of hypertensive heart disease are common in patients with TBAD. LVH predicted all-cause mortality after TBAD in this small group of patients. Further exploration of the relationship between the chronic effects of hypertension and using LVH as an objective biomarker to risk stratify patients with TBAD and long-term outcomes after TBAD is warranted.
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Affiliation(s)
- Alexander P Taylor
- Department of Internal Medicine, University of Washington, Seattle, Wash
| | - Rosario V Freeman
- Division of Cardiology, Department of Internal Medicine, University of Washington, Seattle, Wash
| | | | - Sherene Shalhub
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, Wash.
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20
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Codner JA, Lou X, Duwayri YM, Chen EP, Binongo JN, Moon R, Jordan WD, Leshnower BG. The distance of the primary intimal tear from the left subclavian artery predicts aortic growth in uncomplicated type B aortic dissection. J Vasc Surg 2018; 69:692-700. [PMID: 30292615 DOI: 10.1016/j.jvs.2018.05.245] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 05/31/2018] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Controversy exists about the optimal treatment of acute uncomplicated type B aortic dissection (auTBAD). Optimal medical therapy (OMT) provides excellent short-term outcomes, but long-term results are poor. Ideally, auTBAD patients who will fail to respond to OMT in the chronic phase could be identified and undergo thoracic endovascular aortic repair. The purpose of this study was to identify radiographic predictors of auTBAD patients who will fail to respond to OMT. METHODS A review of the Emory aortic database from 2000 to 2017 identified 320 auTBAD patients initially treated with OMT. From this cohort, 121 patients with two or more contrast-enhanced imaging scans were available for analysis. These patients were initially divided into groups based on growth of the thoracic aorta ≥10 mm or intervention due to aneurysmal growth: growth (n = 72) and no growth (n = 49). TeraRecon (Foster City, Calif) imaging software was used to analyze characteristics of the primary intimal tear (PIT), false lumen, and overall aortic size. Finally, Cox proportional hazards models were constructed to estimate hazard ratios and to identify predictors of OMT failure. RESULTS The mean age of all patients was 54 ± 11 years, and 67% were male. Thirty-eight patients (53%) in the growth group underwent intervention. There were no differences between groups in age, hypertension, diabetes mellitus, tobacco abuse, or chronic obstructive pulmonary disease. The distance of the PIT from the left subclavian artery in patients with auTBAD was significantly shorter in the growth group (growth, 27 mm [9-66 mm]; no growth, 77 mm [26-142 mm]; P < .01). Multivariable Cox regression analysis identified the distance of the PIT from the left subclavian artery and a thoracic aortic diameter >45 mm as independent predictors of failure of OMT. Partial false lumen thrombosis was not a predictor of aortic growth. CONCLUSIONS The distance of the PIT from the left subclavian artery is a predictor of aortic growth in auTBAD. Patients with a primary tear located in zone 3 of the proximal descending thoracic aorta should be monitored closely and may be considered for early thoracic endovascular aortic repair in the setting of auTBAD.
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Affiliation(s)
- Jesse A Codner
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Xiaoying Lou
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Yazan M Duwayri
- Division of Vascular and Endovascular Therapy, Emory University School of Medicine, Atlanta, Ga
| | - Edward P Chen
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Jose N Binongo
- Rollins School of Public Health, Emory University, Atlanta, Ga
| | - Rena Moon
- Rollins School of Public Health, Emory University, Atlanta, Ga
| | - William D Jordan
- Division of Vascular and Endovascular Therapy, Emory University School of Medicine, Atlanta, Ga
| | - Bradley G Leshnower
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Ga.
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21
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Ante M, Mylonas S, Skrypnik D, Bischoff MS, Rengier F, Brunkwall J, Böckler D. Prevalence of the Computed Tomographic Morphological DISSECT Predictors in Uncomplicated Stanford Type B Aortic Dissection. Eur J Vasc Endovasc Surg 2018; 56:525-533. [DOI: 10.1016/j.ejvs.2018.06.033] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 06/13/2018] [Indexed: 10/28/2022]
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22
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Shimamoto T, Komiya T, Tsuneyoshi H. Fate of uncomplicated acute type B aortic dissection and impact of concurrent aortic dilatation on remote aortic events. J Thorac Cardiovasc Surg 2018; 157:854-863. [PMID: 30201125 DOI: 10.1016/j.jtcvs.2018.05.126] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2017] [Revised: 04/08/2018] [Accepted: 05/13/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVE This study aimed to describe the reliable prognostic factors of mortality and subsequent aortic events during the follow-up of uncomplicated type B acute aortic dissection. METHODS From January 2004 to December 2014, 255 patients with uncomplicated type B acute aortic dissection were admitted to our hospital. Cox proportional hazards analysis was performed to identify risk factors for all-cause mortality, aorta-related mortality, and aortic events. RESULTS In-hospital mortality was observed in 7 patients (2.7%). The rates of 5-year freedom from all-cause mortality, aorta-related mortality, and aortic events were 79.4% ± 2.9%, 93.3% ± 2.0%, and 71.7% ± 3.4%, respectively. The rate of 5-year freedom from aortic events was significantly lower among those with a patent false lumen (P = .006). Age and descending aorta diameter were independent risk factors of all-cause and aorta-related mortality (hazard ratio [HR], 1.08 and 1.13; 95% confidence interval [CI], 1.04-1.10 and 1.03-1.24; P = .0001 and .007, respectively). Independent risk factors for aortic events were descending aorta diameter, false lumen thickness, and dilatation of abdominal aorta (HR, 1.06; 95% CI, 1.02-1.12; P = .006; HR, 1.07; 95% CI, 1.04-1.11; P = .00002; HR, 2.01; CI, 1.20-3.38; P = .008). CONCLUSIONS In uncomplicated type B acute aortic dissection, the age and dilatation of the thoracic aorta were associated with a higher risk of death, whereas false lumen thickness and concurrent abdominal aortic dilatation augment the risk for aortic events.
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Affiliation(s)
- Takeshi Shimamoto
- Department of Cardiovascular Surgery, Kurashiki Central Hospital, Okayama, Japan.
| | - Tatsuhiko Komiya
- Department of Cardiovascular Surgery, Kurashiki Central Hospital, Okayama, Japan
| | - Hiroshi Tsuneyoshi
- Department of Cardiovascular Surgery, Kurashiki Central Hospital, Okayama, Japan
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23
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Kazimierczak A, Jedrzejczak T, Rynio P, Waligórski S. Favorable remodeling after hybrid arch debranching and modified provisional extension to induce complete attachment technique in type a aortic dissection: A case report. Medicine (Baltimore) 2018; 97:e12409. [PMID: 30213017 PMCID: PMC6155974 DOI: 10.1097/md.0000000000012409] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Type A aortic dissection (TAAD) usually requires emergency open repair of the ascending aorta. In cases of diffuse dissection that spreads along the descending and abdominal aorta (type I, DeBakey classification), the risk of aneurysmal degeneration varies between 30% and 50% during 5 years and increases even higher during a longer follow-up. Those patients might require complex intervention to prevent aortic rupture. A combination of hybrid arch debranching and the extended provisional extension to induce complete attachment (e-PETTICOAT) technique might be an available alternative in such cases. This is the first report of the successful use of the e-PETTICOAT technique for treating degenerative, diffuse TAAD. PATIENT CONCERNS Acute chest pain and syncope were the initial symptoms of diffuse TAAD in our 66-year-old female patient. Open replacement of the ascending aorta followed by surgical arch debranching was performed as a staged procedure. Unfortunately, progressive aneurysmal degeneration was revealed 6 months later in the thoracic, abdominal, and infrarenal aorta with the recurrence of chest and lumbar pain. DIAGNOSES Computed angiotomography revealed severe aneurysmal degeneration of aortic dissection in the thoracic and abdominal aorta. INTERVENTION The e-PETTICOAT enabled good remodeling and stopped degeneration. OUTCOME At the 2-year follow-up, good remodeling with complete false lumen thrombosis and a stable aortic size were confirmed. LESSON Lifelong follow-up in extensive TAAD should be considered. The e-PETTICOAT technique is an available alternative to fenestrated endovascular aortic repair for degenerative TAAD, as it promotes favorable remodeling after successful surgery of the ascending aorta.
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Affiliation(s)
| | - Tomasz Jedrzejczak
- Department of Cardiosurgery, Pomeranian Medical University in Szczecin, Szczecin, Poland
| | | | - Szymon Waligórski
- Department of Cardiosurgery, Pomeranian Medical University in Szczecin, Szczecin, Poland
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24
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Spinelli D, Benedetto F, Donato R, Piffaretti G, Marrocco-Trischitta MM, Patel HJ, Eagle KA, Trimarchi S. Current evidence in predictors of aortic growth and events in acute type B aortic dissection. J Vasc Surg 2018; 68:1925-1935.e8. [PMID: 30115384 DOI: 10.1016/j.jvs.2018.05.232] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Accepted: 05/31/2018] [Indexed: 01/16/2023]
Abstract
OBJECTIVES Acute type B aortic dissection can have a stable course or evolve into aneurysm and subsequent adverse events. The aim of this systematic review was to analyze the morphologic predictors of an adverse course to establish their validity based on consistency of results. METHODS Fifty-one studies were included in this review, reporting on aortic size, false lumen (FL) size, primary entry tear (ET) size and location, status of FL thrombosis, number of ETs, branch vessels involvement, and FL longitudinal extent. RESULTS Some predictors showed good consistency, whereas others did not. Aortic size was the most investigated predictor. A larger diameter at presentation predicted worse outcomes, with few exceptions. Both FL size and size relative to true lumen size also predicted an adverse course, although a standardized measurement method was not used. Regarding primary ET size and location, evidence was sparse and somewhat conflicting. Although FL complete thrombosis was consistently associated with a more benign course, the role of partial thrombosis remained unclear and the concept of FL saccular formation might account for the inconsistency, but further evidence is needed. A higher number of re-entry tears was considered to be protective against false channel expansion, but results need to be confirmed. The predictive role of branch vessels involvement and FL longitudinal extent remain controversial. CONCLUSIONS Among several predictors of aortic growth and events in acute type B aortic dissection, controversial and even conflicting results have been described. Consistent evidence has been demonstrated only for two predictors: aortic size at presentation is associated with adverse events and total FL thrombosis has a protective role.
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Affiliation(s)
- Domenico Spinelli
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Policlinico G. Martino, University of Messina, Messina, Italy; Thoracic Aortic Research Center, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy; Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Mich.
| | - Filippo Benedetto
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Policlinico G. Martino, University of Messina, Messina, Italy
| | - Rocco Donato
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Policlinico G. Martino, University of Messina, Messina, Italy
| | - Gabriele Piffaretti
- Vascular Surgery, Department of Surgery and Morphological Sciences, Circolo University Teaching Hospital, University of Insubria School of Medicine, Varese, Italy
| | | | - Himanshu J Patel
- Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Mich
| | - Kim A Eagle
- Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Mich
| | - Santi Trimarchi
- Thoracic Aortic Research Center, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy; Department of Scienze Biomediche per la Salute, University of Milan, Milan, Italy
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Matsushita A, Hattori T, Tsunoda Y, Sato Y, Mihara W. Impact of initial aortic diameter and false-lumen area ratio on Type B aortic dissection prognosis†. Interact Cardiovasc Thorac Surg 2017; 26:176-182. [DOI: 10.1093/icvts/ivx286] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2017] [Accepted: 08/03/2017] [Indexed: 01/16/2023] Open
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26
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Li D, Ye L, Yu J, Deng L, Liang L, Ma Y, Yi L, Zeng Z, Cao Y, Wan Z. Significance of the thrombo-inflammatory status-based novel prognostic score as a useful predictor for in-hospital mortality of patients with type B acute aortic dissection. Oncotarget 2017; 8:79315-79322. [PMID: 29108310 PMCID: PMC5668043 DOI: 10.18632/oncotarget.18105] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 05/12/2017] [Indexed: 02/05/2023] Open
Abstract
Background Inflammation and thrombosis are associated with development and progression of acute aortic dissection (AAD). The aim of this study was to assess the prognostic significance of Simplified Thrombo-Inflammatory Prognostic Score (sTIPS), in patients with early phase type B AAD. Methods We retrospectively reviewed 491 patients with type B AAD between November 2012 and September 2015. sTIPS was calculated from the white blood cell count (WBC) and mean platelet volume to platelet count (MPV/PC) ratio, at the time of admission. Patients with both, WBC > 10 (109/L) and MPV/PC ratio > 7.5 (102fL/109L-1) were assigned a score of 2, while patients with high levels of either one or none of the above markers, were assigned scores of 1 and 0 respectively. Multivariable Cox regression analyses were used to investigate the associations between the score and hospital survival. Results Of the 491 type B AAD patients included in this analysis, 24 patients (4.9%) died during hospitalization. Kaplan-Meier analysis revealed that the cumulative mortality was significantly higher in patients with higher sTIPS (P = 0.001). Multivariable Cox regression analysis further indicated that higher sTIPS was a strong predictor of in-hospital mortality after eliminating all confounding factors (sTIPS 2: hazard ratio 4.704, 95%; confidence interval [CI] 1.184-18.685; P = 0.028; sTIPS 1: hazard ratio 1.918, 95%; CI 1.134-3.537; P = 0.045). Conclusions sTIPS at admission was a useful tool for stratifying the risk in type B AAD patients, for outcomes such as in-hospital mortality in the early phase.
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Affiliation(s)
- Dongze Li
- Department of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Lei Ye
- Department of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Jing Yu
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Lixia Deng
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Lianjing Liang
- Department of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Yan Ma
- School of Public Health, Xinjiang Medical University, Urumqi, China
| | - Lei Yi
- Department of Neurology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Zhi Zeng
- Department of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Yu Cao
- Department of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Zhi Wan
- Department of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China
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Abugov SA, Polyakov RS, Pyreckiy MV, Saakyan YM. [Decision making algorithm in distal thoracic aortic dissections]. Khirurgiia (Mosk) 2016:4-10. [PMID: 27804928 DOI: 10.17116/hirurgia2016104-10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- S A Abugov
- Petrovsky Russian Research Center of Surgery; Russian Medical Academy of Postgraduate Education, Health Ministry of the Russian Federation, Moscow, Russia
| | - R S Polyakov
- Petrovsky Russian Research Center of Surgery; Russian Medical Academy of Postgraduate Education, Health Ministry of the Russian Federation, Moscow, Russia
| | - M V Pyreckiy
- Petrovsky Russian Research Center of Surgery; Russian Medical Academy of Postgraduate Education, Health Ministry of the Russian Federation, Moscow, Russia
| | - Yu M Saakyan
- Petrovsky Russian Research Center of Surgery; Russian Medical Academy of Postgraduate Education, Health Ministry of the Russian Federation, Moscow, Russia
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28
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Zhang R, Chen S, Zhang H, Wang W, Xing J, Wang Y, Yu B, Hou J. Biomarkers Investigation for In-Hospital Death in Patients With Stanford Type A Acute Aortic Dissection. Int Heart J 2016; 57:622-6. [PMID: 27593537 DOI: 10.1536/ihj.15-484] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
This retrospective study aimed to investigate the predictive value of biomarkers for in-hospital mortality of patients with Stanford type A acute aortic dissection (AAD).AAD is a life-threatening disease with an incidence of about 2.6-3.6 cases per 100,000/year.A total of 67 consecutive Stanford type A AAD patients admitted to hospital were divided into a deceased group and survival group. The baseline information of the patients between two groups was systematically compared, followed by examination of the electrocardiograms (ECG). Based on the follow-up during hospitalization, we investigated the simultaneous assessment of indexes like fragmented QRS complex (fQRS), admission systolic blood pressure (SBP), aortic diameter, surgical management, troponin I (TnI), white blood cell (WBC) count, N-terminal pro-brain natriuretic peptide (NT-proBNP), and D-dimer.The levels of TnI and NT-proBNP, WBC counts, and rate of fQRS (+) in patients of the deceased group were significantly higher than those in the survival group. The male sex (hazard ratio, 10.88; P = 0.001), admission SBP (hazard ratio, 0.98; P = 0.012), NT-proBNP (hazard ratio, 1.00; P = 0.001), and WBC count (hazard ratio, 1.10; P = 0.033) were independently related with in-hospital death. As a single marker, WBC count had the highest sensitivity at 84.6% (specificity 65.9%).Admission SBP, NT-proBNP, and WBC count were potential independent risk factors of in-hospital death in Stanford type A AAD patients. WBC count may be a more accurate predictor of type A AAD than either alone.
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Affiliation(s)
- Ruoxi Zhang
- Department of Cardiology, The Second Affiliated Hospital of Harbin Medical University
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29
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San Norberto E, Vaquero C. La disección aórtica tipo B: tratamiento endovascular. ANGIOLOGIA 2016. [DOI: 10.1016/j.angio.2015.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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30
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Kamman AV, van Herwaarden JA, Orrico M, Nauta FJH, Heijmen RH, Moll FL, Trimarchi S. Standardized Protocol to Analyze Computed Tomography Imaging of Type B Aortic Dissections. J Endovasc Ther 2016; 23:472-82. [DOI: 10.1177/1526602816642591] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Purpose: To propose a standard measuring protocol for type B aortic dissections so as to improve comparability between studies reporting aortic dimensions. Methods: Fifteen computed tomography (CT) scans of type B aortic dissections were measured with a standard protocol by 2 independent observers using postprocessing software. The following parameters were assessed: true, false, and total lumen diameter; true and false lumen volume; and entry tear size, location, and number. Diameters were measured in a perpendicular plane at 2, 10, and 20 cm from the left subclavian artery and 5 cm from the most distal renal artery. True lumen volume was assessed from the left subclavian artery to the aortic bifurcation, while the false lumen volume was from the start to end up to the aortic bifurcation. Entry tear location was assessed in relation to the left subclavian artery. Intra- and interobserver repeatability and agreement were evaluated using the Bland-Altman method, an a priori set of acceptable differences, and Lin’s concordance correlation coefficient (LCCC). Results: Intra- and interobserver mean differences for aortic diameter and true and false lumen volumes were generally within the limits of agreement and the a priori differences; the LCCC showed excellent agreement. Entry tear location, size, and number were difficult to measure in a repeatable manner, with inconsistent correlation coefficients, especially between the 2 observers. Conclusion: This protocol showed acceptable repeatability for aortic diameter and aortic volume measurements. Assessment of entry tears proved challenging and associated with less favorable results. Additionally, investigators are urged to be more transparent regarding the measurement methodology used in studies describing aortic dimensions.
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Affiliation(s)
- Arnoud V. Kamman
- Thoracic Aortic Research Center, Policlinico San Donato IRCCS, San Donato Milanese, Italy
- Department of Vascular Surgery, University Hospital Utrecht, the Netherlands
| | | | - Matteo Orrico
- Department of Vascular Surgery, San Filippo Neri Hospital, Rome, Italy
| | - Foeke J. H. Nauta
- Thoracic Aortic Research Center, Policlinico San Donato IRCCS, San Donato Milanese, Italy
- Department of Vascular Surgery, University Hospital Utrecht, the Netherlands
- Departments of Surgery and Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Robin H. Heijmen
- Department of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Frans L. Moll
- Department of Vascular Surgery, University Hospital Utrecht, the Netherlands
| | - Santi Trimarchi
- Thoracic Aortic Research Center, Policlinico San Donato IRCCS, San Donato Milanese, Italy
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Afifi RO, Sandhu HK, Leake SS, Boutrous ML, Kumar V, Azizzadeh A, Charlton-Ouw KM, Saqib NU, Nguyen TC, Miller CC, Safi HJ, Estrera AL. Outcomes of Patients With Acute Type B (DeBakey III) Aortic Dissection: A 13-Year, Single-Center Experience. Circulation 2015; 132:748-54. [PMID: 26304666 PMCID: PMC4548541 DOI: 10.1161/circulationaha.115.015302] [Citation(s) in RCA: 97] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Background— Aortic dissection remains the most common aortic catastrophe. In the endovascular era, the management of acute type B aortic dissection (ATBAD) is undergoing dramatic changes. The aim of this study is to evaluate the long-term outcomes of patients with ATBAD who were treated at our center over a 13-year period. Methods and Results— We reviewed patients with ATBAD between 2001 and 2014, analyzing variables based on status (complicated [c] versus uncomplicated [u]) and treatment modalities. We defined cATBAD as rupture, expansion of diameter on imaging during the admission, persistent pain, or clinical malperfusion leading to a deficit in cerebral, spinal, visceral, renal, or peripheral vascular territories at presentation or during initial hospitalization. Postoperative outcomes were defined as deficits not present before the intervention. Outcomes were compared between the groups by use of Kaplan-Meier and descriptive statistics. We treated 442 patients with ATBAD. Of those 442, 60.6% had uATBAD and were treated medically, and 39.4% had cATBAD, of whom 39.0% were treated medically to 30.0% with open repair, 21.3% with thoracic endovascular aortic repair, and 9.7% with other open peripheral procedures. Intervention-free survival at 1 and 5 years was 84.8% and 62.7% for uATBAD, 61.8% and 44.0% for cATBAD-medical, 69.2% and 47.2% for cATBAD-open, and 68.0% and 42.5% for cATBAD–thoracic endovascular aortic repair, respectively (P=0.001). Overall survival was significantly related primarily to complicated presentation. Conclusions— In our experience, early and late outcomes of ATBAD were dependent on the presence of complications, with cATBAD faring worse. Although uATBAD was associated with favorable early survival, late complications still occurred, mandating radiographic surveillance and open or endovascular interventions. Prospective trials are required to better determine the optimal therapy for uATBAD.
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Affiliation(s)
- Rana O Afifi
- From the University of Texas Medical School at Houston and Memorial Hermann Heart & Vascular Institute, Houston
| | - Harleen K Sandhu
- From the University of Texas Medical School at Houston and Memorial Hermann Heart & Vascular Institute, Houston
| | - Samuel S Leake
- From the University of Texas Medical School at Houston and Memorial Hermann Heart & Vascular Institute, Houston
| | - Mina L Boutrous
- From the University of Texas Medical School at Houston and Memorial Hermann Heart & Vascular Institute, Houston
| | - Varsha Kumar
- From the University of Texas Medical School at Houston and Memorial Hermann Heart & Vascular Institute, Houston
| | - Ali Azizzadeh
- From the University of Texas Medical School at Houston and Memorial Hermann Heart & Vascular Institute, Houston
| | - Kristofer M Charlton-Ouw
- From the University of Texas Medical School at Houston and Memorial Hermann Heart & Vascular Institute, Houston
| | - Naveed U Saqib
- From the University of Texas Medical School at Houston and Memorial Hermann Heart & Vascular Institute, Houston
| | - Tom C Nguyen
- From the University of Texas Medical School at Houston and Memorial Hermann Heart & Vascular Institute, Houston
| | - Charles C Miller
- From the University of Texas Medical School at Houston and Memorial Hermann Heart & Vascular Institute, Houston
| | - Hazim J Safi
- From the University of Texas Medical School at Houston and Memorial Hermann Heart & Vascular Institute, Houston
| | - Anthony L Estrera
- From the University of Texas Medical School at Houston and Memorial Hermann Heart & Vascular Institute, Houston.
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Fujikawa T, Yamamoto S, Sekine Y, Oshima S, Kasai R, Mochida Y, Ozaki K, Sasaguri S. Operative Results and Clinical Features of Chronic Stanford Type B Aortic Dissection: Examination of 234 Patients Over 6 Years. Eur J Vasc Endovasc Surg 2015; 50:738-43. [PMID: 26427847 DOI: 10.1016/j.ejvs.2015.07.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Accepted: 07/08/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE/BACKGROUND Recently, the indications for thoracic endovascular aortic repair (TEVAR) have been expanding, and the applicability of TEVAR for acute type B aortic dissection (TBAD) is proposed with regard to the high mortality of open surgery for chronic TBAD. TEVAR in the acute phase may lead to remodeling of the false lumen (FL), but it is controversial whether it completely resolves the aortic expansion in the chronic phase. In this study, operative results and the relationship between FL status and the time before surgical intervention were retrospectively analyzed. METHODS From January 2008 to September 2013, 234 patients underwent open surgery for chronic TBAD. Most patients were on left heart bypass. By considering Japanese aortic disease treatment guidelines and the smaller physique of Japanese patients, operative indications were aneurysm >50 mm in diameter or rapid aneurysm enlargement of >5 mm in a 6 month period. RESULTS In 180 cases, the FL was patent. The mean interval between onset of TBAD and operation was 61 ± 54 months. There was no significant difference between patients in the patent FL group and those in the thrombosed FL group (p = .44). Mean ratio of FL diameter to maximum aortic diameter (FL/AD) was 0.64 ± 0.21. There was no correlation between FL and AD before the operation (r = .12). Descending thoracic aortic replacement (DTAR) was performed in 127 cases and thoracic ascending aortic replacement (TAAR) in 107 cases (Crawford type I, n = 9; Crawford type II, n = 65; Crawford type III and IV, n = 22, respectively; Safi type V, n = 11). The overall operative mortality was 6.8%: 3.9% (5/127) for DTAR and 10.3% (11/107) for TAAR. The three year survival was 86.7, and the freedom from re-intervention rate was 97.0%. CONCLUSION Enlargement of uncomplicated TBAD in the chronic phase was poorly related to FL status and the results of open repair have improved. However, further prospective study is necessary.
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Affiliation(s)
- T Fujikawa
- Kawasaki Aortic Center, Kawasaki Saiwai Hospital, Kawasaki, Japan.
| | - S Yamamoto
- Kawasaki Aortic Center, Kawasaki Saiwai Hospital, Kawasaki, Japan
| | - Y Sekine
- Kawasaki Aortic Center, Kawasaki Saiwai Hospital, Kawasaki, Japan
| | - S Oshima
- Kawasaki Aortic Center, Kawasaki Saiwai Hospital, Kawasaki, Japan
| | - R Kasai
- Kawasaki Aortic Center, Kawasaki Saiwai Hospital, Kawasaki, Japan
| | - Y Mochida
- Kawasaki Aortic Center, Kawasaki Saiwai Hospital, Kawasaki, Japan
| | - K Ozaki
- Kawasaki Aortic Center, Kawasaki Saiwai Hospital, Kawasaki, Japan
| | - S Sasaguri
- Kawasaki Aortic Center, Kawasaki Saiwai Hospital, Kawasaki, Japan
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