Ethnic disparities in outcomes of patients with complicated type B aortic dissection

Race-based outcomes of thoracic aortic aneurysms and dissections in the Global Registry for Endovascular Aortic Treatment

OBJECTIVE

This study characterizes racial differences in presentation, as well as short- and long-term outcomes after endovascular treatment of thoracic aortic aneurysm (TAA) and type B aortic dissection (TBAD).

METHODS

We queried the Gore Global Registry for Endovascular Aortic Treatment for thoracic endovascular aortic repairs (TEVARs) performed between 2010 and 2016 and followed through 2022. Pathologies represented were descending TAA, complicated TBAD, and uncomplicated TBAD. Using standard statistical tests, we compared overall and pathology-specific demographics, procedural factors, and outcomes among Black and White patients undergoing TEVAR.

RESULTS

We identified 438 TEVAR cases, including 236 descending TAA, 121 complicated TBAD, and 74 uncomplicated TBAD. Overall, Black patients were younger and had a higher incidence of renal insufficiency (P = .001), whereas White patients had more chronic obstructive pulmonary disease (P = .003) and cardiac arrhythmias (P = .037). In patients treated for descending TAA, Black patients had increased device- and procedure-related complications (34.3% vs 17.4%; P = .014), conversion to open repair (2.9% vs 0%; P = .011) and type II endoleak (5.7% vs 1.0%; P = .040), but no differences in mortality, length of hospital stay, or major adverse cardiovascular events. Whereas outcomes of TEVAR for uncomplicated TBAD were comparable, Black patients more frequently presented with complicated TBAD than White patients (Black, 40.5% vs White, 24.8%; P = .008) and had subsequently greater reintervention rates (28.1% vs 12.4%; P = .012), all-cause mortality (hazard ratio, 4.28; 95% confidence interval, 1.74-10.5; P = .002) and aortic-related mortality (hazard ratio, 16.7; 95% confidence interval, 1.49-186; P = .022).

CONCLUSIONS

Despite increased device- and procedure-related complications, similar short- and long-term outcomes are achieved in Black and White patients undergoing TEVAR for descending TAA and uncomplicated TBAD. However, Black patients are more likely to present with, require reintervention for, and suffer mortality from complicated TBAD.

A systematic review supporting the Society for Vascular Surgery guidelines on the management of heritable aortopathies

BACKGROUND

To support the development of clinical practice guidelines on the management of patients with genetic aortopathies and arteriopathies, a writing committee from the Society for Vascular Surgery has commissioned this systematic review.

METHODS

We conducted a systematic review and searched multiple databases for studies addressing six questions identified by the Society for Vascular Surgery guideline committee about evaluating and managing patients with genetic aortopathies and arteriopathies. Studies were selected and appraised by pairs of independent reviewers.

RESULTS

We included 12 studies in this systematic review. We did not identify studies about the long-term outcomes of endovascular repair for aortic aneurysm in patients with heritable aortopathy or about new aortic events in pregnant women with a history of aortic dissection (AD) or aneurysm. A small case series demonstrated a 100% survival rate and 100% aortic intervention-free survival at 15 months (range, 7-28 months) after endograft repair for type B AD. A positive genetic diagnosis was discovered in 36% of patients with aortic aneurysms and dissections who had no risk factors for hereditary aortopathies, and these patients had a mortality rate of 11% at a median follow-up duration of 5 months. Black patients had lower 30-day mortality than White patients (5.6% vs 9.0%, respectively), but they had a higher overall aortic reintervention rate at 30 days after AD repair (47% vs 27%, respectively). Aortic reinterventions owing to aneurysmal expansion and endoleak at 30 days were higher in Black patients than White patients. The certainty of evidence was judged to be very low across all the outcomes evaluated in this systematic review.

CONCLUSIONS

The available evidence suggests high survival after thoracic endovascular aortic repair for type B AD in young patients with heritable aortopathies, but with limited long-term follow-up. Genetic testing in patients with acute aortic aneurysms and dissections had a high yield. It was positive for most patients with risk factors for hereditary aortopathies and in more than one-third for all other patients, and was associated with new aortic events within 15 years.

Racial and ethnic differences in presentation severity and postoperative outcomes in vascular surgery

BACKGROUND

We assessed the effect of race and ethnicity on presentation severity and postoperative outcomes in those with abdominal aortic aneurysms (AAAs), carotid artery stenosis (CAS), peripheral arterial disease (PAD), and type B aortic dissection (TBAD).

METHODS

MEDLINE, Embase, and Cochrane Central Register of Controlled Trials from inception until December 2020. Two reviewers independently selected randomized controlled trials and observational studies reporting race and/or ethnicity and presentation severity and/or postoperative outcomes for adult patients who had undergone major vascular procedures. They independently extracted the study data and assessed the risk of bias using the Newcastle-Ottawa scale. The meta-analysis used random effects models to derive the odds ratios (ORs) and risk ratios (RRs) and their corresponding 95% confidence intervals (CIs). The primary outcome was presentation severity stratified by the proportion of patients with advanced disease, including ruptured vs nonruptured AAA, symptomatic vs asymptomatic CAS, chronic limb-threatening ischemia vs claudication, and complicated vs uncomplicated TBAD. The secondary outcomes included postoperative all-cause mortality and disease-specific outcomes.

RESULTS

A total of 81 studies met the inclusion criteria. Black (OR, 4.18; 95% CI, 1.31-13.26), Hispanic (OR, 2.01; 95% CI, 1.85-2.19), and Indigenous (OR, 1.97; 95% CI, 1.39-2.80) patients were more likely to present with ruptured AAAs than were White patients. Black and Hispanic patients had had higher symptomatic CAS (Black: OR, 1.20; 95% CI, 1.04-1.38; Hispanic: OR, 1.32; 95% CI, 1.20-1.45) and chronic limb-threatening ischemia (Black: OR, 1.67; 95% CI, 1.14-2.43; Hispanic: OR, 1.73; 95% CI 1.13-2.65) presentation rates. No study had evaluated the effect of race or ethnicity on complicated TBAD. All-cause mortality was higher for Black (RR, 1.23; 95% CI, 1.01-1.51), Hispanic (RR, 1.90; 95% CI, 1.57-2.31), and Indigenous (RR, 1.24; 95% CI, 1.12-1.37) patients after AAA repair. Postoperatively, Black (RR, 1.54; 95% CI, 1.19-2.00) and Hispanic (RR, 1.54; 95% CI, 1.31-1.81) patients were associated with stroke/transient ischemic attack after carotid revascularization and lower extremity amputation (RR, 1.90; 95% CI, 1.76-2.06; and RR, 1.69; 95% CI, 1.48-1.94, respectively).

CONCLUSIONS

Certain visible minorities were associated with higher morbidity and mortality across various vascular surgery presentations. Further research to understand the underpinnings is required.

Racial Diversity and Black Vascular Surgeons in Vascular Surgery Workforce

OBJECTIVES

The precise number of actively practicing vascular surgeons who self-identify as Black and the historical race composition trends within the overall profession of vascular surgery are unknown. Limited demographic data has been collected and maintained at the societal or national board level. Vascular Surgery Societal reports suggest that less than 2% of vascular surgeons identify as Black. Blacks make up 13.4% of the American population yet for disorders such as peripheral arterial disease and end stage renal disease, Black communities are disproportionately impacted, and the prevalence of disease is greater on an age adjusted basis. Significant body of research showed that clinical outcomes like medication adherence, shared decision making, and research trial participation are positively impacted by racial concordance especially for communities in whom distrust is high as a consequence of historic experiences. This survey aims to characterize practice and career variables within a network of Black vascular surgeons.

METHODS

A cross sectional survey was conducted via a questionnaire sent to all participants of a Society of Black Vascular Surgeons (SBVS) that began to convene monthly during the COVID-19 pandemic and experienced subsequent organic growth. The survey included 20 questions with variables quantified including the surgeon's demographics, clinical experience, practice setting, patient demographics and professional society engagement.

RESULTS

Fifty-nine percent of the SBVS members completed the survey. Males compromised 81% of the responding vascular surgeons. The majority (62%) of respondents are involved in academic practice. Less than 25% percent of the total medical staff was Black in 77% of the respondents' current work practice. The patient racial composition within their respective practice settings: White (47%), Black (34%), Hispanic (13%), Asian (3%), Middle Eastern or North African (2%) and American Indian and Alaskan Natives (0.4%). Forty three percent of respondents have a current active membership in the Society of Vascular Surgery and 24% have regional society membership. Fifty-eight percent of respondents reported that they experienced workplace event that they felt were racially or ethically driven in the 12 months prior to the survey.

CONCLUSION

This survey describes an underrepresented in medicine (URM) vascular surgeon subgroup that has not heretofore been characterized. Racial and ethnic demographic data are essential to better understand the current demographic makeup of our specialty, and to develop benchmark goals of race composition that mirrors our society at large. In this group of Black vascular surgeons, their patients were more likely to represent a racial minority. Efforts to increase race diversity in vascular surgery have the potential benefit of enhancing care of patients with vascular disease.

Ethnic Disparities in CT Aortography Use for Diagnosing Acute Aortic Syndrome

Purpose

To determine whether CT aortography was performed in proportion to patient risk for acute aortic syndrome (AAS) and incidence of AAS for different ethnic groups.

Materials and Methods

All atraumatic thoracic aorta CT aortographic examinations performed in adults (age > 15 years) suspected of having AAS between January 2009 and December 2019 at Auckland City Hospital (New Zealand) were included. Patients were risk stratified using the aortic dissection detection risk score (ADD-RS). The primary outcomes were the ratio of CT aortography rates to rates of positive CT aortographic examinations and the incidence of AAS. Population census data were used to determine age-standardized incidence of AAS in the emergency department (ED).

Results

In total, 1646 CT aortographic examinations were performed in 1543 patients (mean age, 62 years ± 16 [SD]; 877 male patients). Māori (34% [68 of 203]) and Pacific Islanders (35% [80 of 229]) were more likely to be at high risk of AAS (ADD-RS > 1) compared with patients from other ethnic groups (25% [308 of 1214]); in the ED catchment population, age-standardized AAS incidence was significantly higher in Māori (6.9 per 100 000 person-years [95% CI: 4.3, 10.4]) and Pacific Islanders (5.3 [95% CI: 3.4, 7.8]) than in other ethnic groups (2.3 [95% CI: 1.8, 2.8]). Despite this higher incidence, disproportionately fewer CT aortographic examinations were requested in the ED for Māori (9.2 CT aortographic examinations per AAS diagnosis) and Pacific Islanders (9.2 CT aortographic examinations per AAS diagnosis) compared with other ethnic groups (13.8 CT aortographic examinations per AAS diagnosis).

Conclusion

Māori and Pacific Islanders were at disproportionately higher risk of AAS but had fewer requested CT aortographic examinations compared with other ethnic groups. This increased risk of AAS in Pacific Islander and indigenous Māori patients should be considered by clinicians when investigating AAS.Keywords: Ethnicity, Māori, Pacific Islander, Aortic Dissection Detection Risk Score, Acute Aortic Syndrome, Aortic Dissection, CT Angiography Supplemental material is available for this article. © RSNA, 2022.

Disparities in reporting and representation by sex, race, and ethnicity in endovascular aortic device trials

OBJECTIVE

Vulnerable populations, including women and racial and ethnic minorities, have been historically underrepresented in clinical trials. We, therefore, studied the demographics of patients enrolled in pivotal endovascular aortic device trials in the United States.

METHODS

We queried the Food and Drug Administration (FDA) medical devices database for all FDA-approved endografts for the treatment of aortic aneurysms, transections, and dissections from September 1999 to November 2021. These included abdominal endovascular aortic repair (EVAR), thoracic EVAR (TEVAR), fenestrated EVAR (FEVAR) devices, and dissection stents. Multiple cases of approval for expanded indications were included separately. The primary outcomes included the proportion of trials reporting participant sex, race, and ethnicity and the proportion of enrolled participants across sex, racial, and ethnic groups.

RESULTS

The FDA provided 29 approvals from 29 trials of 24 devices: 15 EVAR devices (52%), 12 TEVAR devices (41%), 1 FEVAR device (3.4%), and 1 dissection stent (3.4%). These trials had included 4046 patients. Of the 29 trials, all had reported on the sex of the participants, and the median female enrollment was 21% (interquartile range [IQR], 11%-34%). The EVAR trials had the lowest female enrollment (11%; IQR, 8.7%-13%) compared with 41% (IQR, 27%-45%) in the TEVAR trials, 21% in the FEVAR trial, and 34% in the dissection stent trial (P < .01 for the difference). Only 52% of the trials had reported the three most common racial groups (White, Black, Asian), and only 48% had reported Hispanic ethnicity. The TEVAR trials were the most likely to report all three racial groups and Hispanic ethnicity (92% and 75%, respectively), while the EVAR trials had the lowest reporting rates (13% and 20%, respectively). Where reported, the median enrollment of racial and ethnic groups across the trials was as follows: Black patients, 9.8% (FEVAR, 0%; EVAR, 1.9%; TEVAR, 12%; dissection stent, 25%; P = .01); Asian patients, 2.4% (EVAR, 0.6%; FEVAR, 2.4%; TEVAR, 2.5%; dissection stent, 11%; P = .24); and Hispanic patients, 3.8% (EVAR, 1.3%; FEVAR, 2.4%; TEVAR, 3.9%; dissection stent, 4.1%; P = .75).

CONCLUSIONS

Racial and ethnic minority groups were underrepresented and underreported in pivotal aortic device trials that led to FDA approval. Female patients were also underrepresented in these aortic trials, especially for EVAR. These data suggest the need for standardization of reporting practices and minimum thresholds for minority and female participation in pivotal trials to promote equitable representation.

Racial Disparities in Presentation and Short-Term Outcomes in Patients with Acute Type B Aortic Dissection

OBJECTIVE

Racial disparities in cardiovascular risk factors and disease outcomes are well documented. A knowledge gap exists on the role health maintenance plays in the development and outcomes of type B aortic dissection (TBAD). This study aims to evaluate the comparative presentation and short-term outcomes of patients with TBAD across race.

METHODS

In this single center retrospective study, TBAD patients admitted to the intensive care unit (ICU) were identified from 2015 to 2020. Patients self-identified as Black (N= 57) and White (N=123) were included. Groups were compared on variables including demographics, socioeconomic, pre-event health maintenance. Socioeconomic disadvantage was quantified based on The Area Deprivation Index (ADI). Management strategies included nonoperative and surgical repair. Outcomes were 30-day mortality, length of stay (LOS), and Acute Physiology and Chronic Health Evaluation (APACHE II) score.

RESULTS

The study included 180 consecutive patients with TBAD. TBAD included complicated (n= 42) and uncomplicated (n=138), of which (n=79) had high risk features. Blacks were younger than Whites (58.9 vs 67.6; p< 0.01), more likely to have end stage renal disease (ESRD) (8.8% vs 0.8%; p= 0.01) and to present with anemia (10.5% vs 2.4%; p=0.03). TBAD anatomic features and management were similar in both groups. Surgical intervention during hospitalization was 40% and 46% in Blacks and Whites, respectively (p= 0.4). Black patients were more likely to be on 3 or more hypertension agents, (42.2% vs 16.4%; p= 0.005) and less likely to be adherent to prescribed agents (27.1% vs 6.7%; p<0.001). Black patients had fewer primary care physician (PCP) visits prior to TBAD event (p= 0.03) and more Emergency Department (ED) utilization prior to TBAD, (57.9% vs 26.9% ;p < 0.001). Black patients had higher ADI scores, 86.0 ± 14.6 vs 64.4 ± 21.3 (p < 0.001). Median [IQR] APACHE II score was the same in both Blacks and Whites, 9[6, 12] and 9[7, 13] respectively (p=0.7). Hospital median LOS (days) was identical in both groups 7 [5, 13]. Readmission was 24.5% in Blacks vs 15.5% in Whites (p=0.16) with a 30-day mortality similar in Blacks 7.0% vs 5.7% Whites (p= 0.7).

CONCLUSION

Black patients present younger with similar dissection morphology, rate of anatomic high risk features and APACHE II scores. Fewer PCP visits, greater ED utilization, and higher ADI suggest lower health maintenance in Black patients. White patients with TBAD were also highly deprived of health maintenance compared to the national percentile, indicating that TBAD is a disease that affects vulnerable populations regardless of race.

Ethnic differences in incidence and outcomes of acute aortic syndromes in the Midland region of New Zealand

BACKGROUND

Disparities in cardiovascular disease according to socioeconomic factors and ethnicity are a global issue. The indigenous Māori population of New Zealand is not exempt. The aims of the present study were to assess whether ethnic disparities exist in the presentation and outcomes of acute aortic syndrome (AAS), including aortic dissection, intramural hematoma, and penetrating aortic ulcer, in New Zealand.

METHODS

A retrospective observational cohort study of consecutive AAS patients presenting to a tertiary referral center covering the Midland region of New Zealand (population, 816,900; 23.3% Māori) during a 10-year period was completed (2010-2020). Data were assessed by ethnicity (Māori vs non-Māori) and Stanford classification of AAS. The incidence of disease, 30-day mortality, and long-term all-cause and aortic-related mortality were recorded and assessed using logistic regression and Cox proportional hazards models.

RESULTS

A total of 250 patients had presented with AAS (Māori, 92 [36.8%]; type A, 144 [57.6%]). The age-standardized rates of AAS were higher in Māori than in non-Māori patients (6.9/100,000 person-years vs 2.0/100,000 person-years; risk ratio, 3.56; 95% confidence interval, 1.50-8.53; P = .002). Māori patients had presented at a younger age for both type A (age, 54.4 ± 12 years vs 66.0 ± 13.2 years; P < .001) and type B (age, 61.3 ± 10.2 years vs 68.8 ± 13.7 years; P = .005) AAS. Mortality at 30 days was higher for those with type A than for those with type B AAS (33.3% vs 13.2%; P < .001) but did not differ by ethnicity in our cohort. On multivariate analysis, no differences were found in 30-day or long-term survival when stratified by ethnicity.

CONCLUSIONS

The results from the present study have demonstrated that ethnic disparities in AAS exist in New Zealand, with Māori presenting at a younger age and with a greater incidence compared with other ethnicities. Whether this disparity is related to socioeconomic factors, access to preventive care, or other factors remains to be elucidated. Despite these differences in disease presentation, the survival outcomes when stratified by ethnicity were comparable in the present cohort.

Analysis of racial disparities in acute type A aortic dissection repair at a rural tertiary academic medical center

BACKGROUND

To determine if racial disparities exist between African Americans (AA) and Non-Hispanic Whites (NHW) for patients undergoing repair of acute type A aortic dissection (ATAAD) at a rural tertiary academic medical center.

METHODS

There were 215 consecutive AA and NHW patients who underwent ATAAD repair at our institution from 1999 to 2019 included in a retrospective analysis of our Society of Thoracic Surgeons Adult Cardiac Surgery Database. Statistical analysis was performed with a p value of less than .05 considered statistically significant.

RESULTS

Patients undergoing ATAAD repair were 47% AA despite comprising only 27% of the total population in our region. AAs were significantly younger (54.0 vs. 61.2 years), were more likely to be hypertensive (94.1% vs. 79.7%), had higher creatinine levels (1.7 vs. 1.1 mg/dL), and higher body mass index (30.8 vs. 28.1 kg/m² ) (all p values < .006). There were no significant differences in type of repair or intraoperative variables. A logistic regression analysis showed AAs had an increased rate of postoperative acute renal failure not requiring hemodialysis when compared to NHWs (20.8% vs. 10.6%, p value = .042). Thirty-day mortality was not significantly different (15.7% vs. 13.4%) nor was 1-year survival (78% vs. 79%) in AAs and NHWs, respectively.

CONCLUSIONS

Despite AAs having more medical comorbidities at presentation, there were no differences in short- and intermediate-term survival. In our catchment of 1.8 million people, AAs appear to undergo ATAAD repair at a disproportionate rate versus NHWs. These findings may alter strategies for surveillance and prevention of aortic disease in this high-risk population.

Predictors of adverse events in uncomplicated type B aortic dissection: a systematic review with meta-analysis

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.

Genetic aortic disease epidemiology, management principles, and disparities in care

Patients with syndromic and nonsyndromic heritable aortopathies (also known as genetic aortic disease) are a heterogeneous group of patients who present at younger ages with more rapid growth of aortic aneurysms and/or increased frequency of dissections compared with patients with atherosclerotic aortopathies. In this review, we describe the etiology, epidemiology, and appropriate care delivery for these conditions at each stage of management. Within each section, we discuss sex, gender, and race differences and highlight disparities in care and knowledge. We then discuss the role of the vascular team throughout the cycle of care and the evolving inclusion of patient input in research. This understanding is essential to the creation of effective health care policies that support equitable, appropriate, and patient-centered clinical practices.

Epidemiology of aortic dissection

Aortic dissection remains a highly morbid diagnosis. The treatment of aortic dissection has undergone several paradigm shifts since it was first understood. However, despite the robust research in treatment, the epidemiology of aortic dissection is limited. In this review, we discuss the historical perspectives of aortic dissection with a review of risk factors and presentation. We review the trends in incidence during the past 40 years, with consideration for sex, race, and ethnicity in admission. We further focus our discussion of the classically described Type B aortic dissection treatment. Lastly, we review the impact of long-term events, readmissions, cost assessments, and quality of life studies of patients with aortic dissection. Care for those with aortic dissection remains a long-term challenge for providers and a multispecialty approach is needed for complete patient management.

Black patients have a higher burden of comorbidities but a lower risk of 30-day and 1-year mortality after thoracic endovascular aortic repair

BACKGROUND

Racial disparities in open thoracic aortic aneurysm repair have been well-documented, with Black patients reported to suffer from poor outcomes compared with their White counterparts. It is unclear whether these disparities extend to the less invasive thoracic endovascular aortic repair (TEVAR). This study aims to examine the clinical characteristics, perioperative outcomes, and 1-year survival of Black vs White patients undergoing TEVAR in a national vascular surgery database.

METHODS

The Vascular Quality Initiative database was retrospectively queried to identify all patients who underwent TEVAR between January 2011 and December 2019. The primary outcomes were 30-day mortality and 1-year survival after TEVAR. Secondary outcomes included various types of major postoperative complications. Multivariable logistic regression analyses were performed to identify predictors of 30-day mortality and perioperative complications. Multivariable Cox regression analysis was used to determine the predictors of 1-year survival.

RESULTS

A total of 2669 patients with TEVAR were identified in the Vascular Quality Initiative, of whom 648 were Black patients (24.3%). Compared with White patients, Black patients were younger and had a higher burden of comorbidities, including hypertension, diabetes, congestive heart failure, dialysis dependence, and anemia. Black patients were more likely to be symptomatic, present with aortic dissection, and undergo urgent or emergent repair. There was no statistically significant difference in 30-day mortality between Black and White patients (3.4% vs 4.9%; P = .1). After adjustment for demographics, comorbidities, and operative factors, Black patients were independently associated with a 56% decrease in 30-day mortality risk compared with their White counterparts (odds ratio, 0.44; 95% confidence interval [CI], 0.22-0.85; P = .01) and not associated with an increased risk of perioperative complications (odds ratio, 0.90; 95% CI, 0.68-1.17; P = .42). Black patients also had a significantly better 1-year overall survival (log-rank, P = .024) and were associated with a significantly decreased 1-year mortality (hazard ratio, 0.65; 95% CI, 0.47-0.91; P = .01) after adjusting for multiple clinical factors.

CONCLUSIONS

Although Black patients carried a higher burden of comorbidities, the racial disparities in perioperative outcomes and 1-year survival do not persist in TEVAR.

Risk factors of distal segment aortic enlargement after complicated type B aortic dissection

Objectives

Distal segment aortic enlargement (DSAE) is a common complication that influences the long-term prognosis of type B aortic dissection (TBAD) after thoracic endovascular aortic repair (TEVAR). In this study, a multivariate analysis was performed to find potential factors predictive of DSAE.

Methods

A single-center retrospective study was performed from 1999 to 2016. Included in the study were complicated TBAD patients who underwent TEVAR with uncovered residual tears. Based on the diameter of the distal segment of the uncovered aorta, we assigned patients to an enlargement group and a non-enlargement group. Data extracted from the medical records included demographic and clinical characteristics and follow-up computed tomography angiography data. The primary endpoints were the all-cause mortality and the presumably aortic-related events that required reintervention during the follow-up period.

Results

For the 333 patients, all-cause mortality was 38 (11.41%), and 76 (22.82%) patients underwent reintervention. A total of 70 (21.02%) patients experienced DSAE, among them were 2 patients who died of aortic rupture and 58 patients who accepted reintervention. Multivariate analysis reviewed independent risk factors of postoperative DSAE, including current smoking, the residual length of the patent false lumen, the postoperative number of dissection tears in the thoracic aorta and type III aortic arch; as well as protective factors, including the application of a restrictive bare stent (RBS), the length of covered stent in the descending thoracic aorta, and the distance from the residual first tear to the left subclavian artery (LSA).

Conclusion

DSAE after TEVAR for patients with a complicated TBAD can be influenced by their current smoking habit, the residual length of patent false lumen, the postoperative number of dissection tears in the thoracic aorta and the aortic arch type. Meanwhile, RBS usage, the length of the covered stent in the descending thoracic aorta and the distance from the residual first tear to the LSA could have positive effect on the prognosis.

Cocaine use is associated with worse outcomes in patients treated with thoracic endovascular repair for type B aortic dissection

OBJECTIVE

To describe and compare the clinical and anatomical characteristics and outcomes of patients with and without known cocaine use who underwent thoracic endovascular repair for type B aortic dissections.

METHODS

Between January 2012 and January 2017, 186 patients underwent thoracic endovascular repair for type B aortic dissection at our institution. Clinical data and anatomical characteristics were collected under an institutional review board-approved protocol. Survival, reintervention, complications, and characteristics of dissection were compared between patients with cocaine use (C+; n = 14) and those with no known cocaine use (C-; n = 172).

RESULTS

Cocaine users were more likely to be young African American males who smoked. They tended to present with more extensive dissections as evidenced by larger false lumen diameters. They also had higher rates of endoleaks and more reinterventions.

CONCLUSIONS

These results suggest that special care should be taken to provide close follow-up for these patients.