Burden and causes of readmissions following initial discharge after aortic syndromes

Novel insights into thoracic endografts technology for prevention of distal stent-graft induced new entry (dSINE) following endovascular repair of type B aortic dissections: from bench to bedside

INTRODUCTION

Endovascular treatment of type B aortic dissections (TBAD) has currently acquired a primary therapeutic role when anatomically feasible. The main issue with thoracic endovascular aortic repair (TEVAR) for aortic dissection is the actual nature of the aortic wall, which is structurally compromised and more fragile. Indeed, a wealth of data have shown that TEVAR for TBAD will lead, in a substantial proportion of cases, to a device-related adverse event named distal stent-graft induced new entry (dSINE).

AREAS COVERED

Currently available aortic stent-grafts have not been specifically devised for the treatment of aortic dissection. A novel dissection specific stent-graft (DSSG) was developed, which is a custom-made device based on the Zenith Alpha Thoracic platform (Cook Medical). The DSSG has several unique properties that, in principle, make its use optimal in TBAD patients.

EXPERT OPINION

TEVAR in the setting of aortic dissections remains technically challenging. The occurrence of dSINE represents a unique complication in this scenario and may lead to high rates of aortic-related adverse events and need for secondary interventions. The use of a novel custom-made DSSG in the setting of chronic TBAD has been proven to be safe, feasible and effective. However, even this approach may fail to completely prevent dSINE formation.

Efficacy and Safety of Exercise Testing and Rehabilitation for Aortic Dissection Patients: A SCOPING REVIEW

OBJECTIVE

Although physical exercise has established benefits for long-term cardiovascular health, concern regarding further aortic events has limited the evidence for exercise among aortic dissection (AD) patients. The objective was to perform a scoping review of the current concepts and gaps in the literature regarding the benefit and safety of cardiovascular testing and rehabilitation among post-AD patients.

REVIEW METHODS

A scoping review of the literature search was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Eligibility criteria included any studies with AD in relation to exercise rehabilitation or testing and physical or mental health. Electronic databases were queried for relevant studies (last queried, November 1, 2021).

RESULTS

Six observational studies were included with a total of 381 patients with AD, all of whom underwent surgical intervention. Study heterogeneity prevented data synthesis and a formal systematic review, although four dominant themes emerged: cardiovascular-related outcomes, aorta-related outcomes, quality of life (QoL), and serious adverse events. Patients with AD have reduced baseline physical capacity and QoL. Rehabilitation programs may increase both physical status and QoL. Rates of serious adverse rates are minimal yet poorly defined.

CONCLUSIONS

Within the context of apparent benefits from cardiovascular testing and rehabilitation for patients with AD who have undergone intervention, this scoping review highlights the need for increased comparative research specific to exercise among patients with AD and outcomes such as mortality and reinterventions.

Long-term Survival After Repair of Ruptured Abdominal Aortic Aneurysms Is Improving Over Time: Nationwide Analysis During Twenty-four Years in Sweden (1994-2017)

OBJECTIVE

To investigate long-term survival after ruptured abdominal aortic aneurysms (rAAA) repair in Sweden during twenty-four years (1994-2017).

SUMMARY BACKGROUND DATA

Management of rAAA has seen significant changes in the past decades, with the shifting from open (OAR) to endovascular (EVAR) being the most striking, thereby enabling treatment of elderly patients with multiple comorbidities.

METHODS

A registry-based nationwide cohort study was performed, and three 8-year periods (1994-2001, 2002-2009, 2010-2017) were compared for crude long-term survival with Kaplan-Meier and multivariable Cox proportional hazards analyses. Relative survival compared to matched general population referents was estimated.

RESULTS

Overall, 8928 rAAA repair subjects were identified (1994-2001 N = 3368; 2002-2009 N = 3405; 2010-2017 N = 2155). The proportion of octogenarians (20.6%; 27.5%; 34.0%; P < 0.001), women (14.3%; 18.5%; 20.6%; P < 0.001), and EVAR procedures (1.5%; 14.9%; 35.5%; P < 0.001) increased over time. The crude 5-year survival was 36%; 44%; 43% (P < 0.0001). Multivariable Cox proportional hazard analysis displayed a decreasing mortality hazard ratio (HR) over time (1.00; 0.80; 0.72; P < 0.001). Use of EVAR was associated with reduced hazards of crude long-term mortality (HR = 0.80, P < 0.001). Relative survival for patients surviving the perioperative period (ie, 90 days) was lower than matched general population referents, and was stable over time (relative 5-year survival: 86% vs 88%, vs 86% P < 0.001).

CONCLUSIONS

Nationwide analysis of long-term outcomes after repair of rAAA in Sweden during 24 years (1994-2017) has revealed that, despite changes in the baseline population characteristics as well as in the treatment strategy, long-term survival improved over time.

Nationwide database analysis of one-year readmission rates after open surgical or thoracic endovascular repair of Stanford Type B aortic dissection

Objective

We examined readmissions and resource use during the first postoperative year in patients who underwent thoracic endovascular aortic repair or open surgical repair of Stanford type B aortic dissection.

Methods

The Nationwide Readmissions Database (2016-2018) was queried for patients with type B aortic dissection who underwent thoracic endovascular aortic repair or open surgical repair. The primary outcome was readmission during the first postoperative year. Secondary outcomes included 30-day and 90-day readmission rates, in-hospital mortality, length of stay, and cost. A Cox proportional hazards model was used to determine risk factors for readmission.

Results

During the study period, type B aortic dissection repair was performed in 6456 patients, of whom 3517 (54.5%) underwent thoracic endovascular aortic repair and 2939 (45.5%) underwent open surgical repair. Patients undergoing thoracic endovascular aortic repair were older (63 vs 59 years; P < .001) with fewer comorbidities (Elixhauser score of 11 vs 17; P < .001) than patients undergoing open surgical repair. Thoracic endovascular aortic repair was performed electively more often than open surgical repair (29% vs 20%; P < .001). In-hospital mortality was 9% overall and lower in the thoracic endovascular aortic repair cohort than in the open surgical repair cohort (5% vs 13%; P < .001). However, the 90-day readmission rate was comparable between the thoracic endovascular aortic repair and open surgical repair cohorts (28% vs 27%; P = .7). Freedom from readmission for up to 1 year was also similar between cohorts (P = .6). Independent predictors of 1-year readmission included length of stay more than 10 days (P = .005) and Elixhauser comorbidity risk index greater than 4 (P = .033).

Conclusions

Approximately one-third of all patients with type B aortic dissection were readmitted within 90 days after aortic intervention. Surprisingly, readmission during the first postoperative year was similar in the open surgical repair and thoracic endovascular aortic repair cohorts, despite marked differences in preoperative patient characteristics and interventions.

TEVAR and EVAR, the unknown knowns of the cardiovascular hemodynamics; and the immediate and long-term consequences of fabric material on major adverse clinical outcome

This review discusses the impact of endovascular aneurysm repair on cardiovascular (CV) hemodynamics and the role of stent-graft material, i.e., polytetrafluoroethylene (PTFE) vs. polyester in post-procedural outcomes. Endovascular aneurysm repair has been widely employed in the last decades for thoracic and abdominal aneurysm repair. However, aortic endografts are stiff and alter the native flow hemodynamics. This failure to simulate the native aorta could lead to added strain on the heart, manifesting as increased left ventricular strain, higher pulse pressure, and congestive heart failure later. This could result in adverse CV outcomes. Also, evidence is mounting to support the implication of stent-graft materials, i.e., PTFE vs. polyester, in adverse post-procedural outcomes. However, there is an absence of level one evidence. Therefore, the only way forward is to plan and perform a randomised controlled trial to demonstrate the alterations in the CV hemodynamics in the short and long run and compare the available stent-graft materials regarding procedural and clinical outcomes. We believe the best solution, for now, would be to reduce the stented length of the aorta. At the same time, in the longer term, encourage continuous improvement in stent-graft materials and design.

Emergency Department Visits After Acute Aortic Syndromes

OBJECTIVES

Recent reports document a high rate of readmission after hospitalization for acute aortic syndromes (AAS) that include acute aortic dissections (AD), intramural hematomas (IMH), or penetrating aortic ulcers (PAU). We examined the rate of return to the emergency department (ED) to better understand the utilization of emergent health care services after AAS.

METHODS

Consecutive AAS patients admitted to the vascular surgery service from 2004 to 2020 were included. Patients with type A dissections, arch involvement, or chronic aortic pathology were excluded. The primary outcome was ED visits within 90 days of the original hospitalization.

RESULTS

The study included 79 subjects (62% men, 38% women; mean age, 64+14 years) with AAS (82% AD, 11% IMH, 6% PAU). A total of 54 ED visits related to the AAS occurred within 90 days of the original discharge, each of which incurred a CT angiogram. Twenty-eight (35%) subjects had a mean of 2+2 ED visits, while 51 (65%) subjects had no ED visits. Ninety percent (25/28) of the first ED visits occurred within 1 month of discharge and 53% (15/28) within one week. 17 (61%) subjects were readmitted to the hospital from the ED. Four subjects were found to have progression of AAS on imaging studies and underwent TEVAR during readmission. Comparing subjects who returned to the ED to those who did not, there were no significant differences in demographics, atherosclerotic risk factors except coronary artery disease, type of AAS, number of antihypertensive medications at admission or discharge, operative intervention, length of initial hospital stay, or discharge status. The chief complaint at the first ED visit was pain (n=17), uncontrolled hypertension (n=5), syncope (n=3), and other (n=3).

CONCLUSIONS

These data show that one in three patients with AAS returned to the ED within 90 days of initial discharge. Although returning subjects had a higher number of readmissions, few had progression of AAS that required intervention. Because the vast majority were readmitted for medical therapy, early and frequent clinic follow up may help decrease ED visits and readmissions after AAS.

Predictors of Long-Term Aortic Growth and Disease Progression in Patients with Aortic Dissection, Intramural Hematoma, and Penetrating Aortic Ulcer

BACKGROUND

We aimed to identify predictors of long-term aortic diameter change and disease progression in a population cohort of patients with newly diagnosed aortic dissection (AD), intramural hematoma (IMH), or penetrating aortic ulcer (PAU).

METHODS

We used the Rochester Epidemiology Project record linkage system to identify all Olmsted County, MN-USA, residents diagnosed with AD, IMH, and PAU (1995-2015). The endpoints were aortic diameter change, freedom from clinical disease progression (any related intervention, aortic aneurysm, new aortic syndrome, rupture or death) and disease resolution (complete spontaneous radiological disappear). Linear regression was used to assess aortic growth rate; predictors of disease progression were identified with Cox proportional hazards.

RESULTS

Of 133 incident cases, 46 ADs, 12 IMHs, and 28 PAUs with sufficient imaging data were included. Overall median follow-up was 8.1 years. Aortic diameter increase occurred in 40 ADs (87%, median 1.0 mm/year), 5 IMHs (42%, median 0.2 mm/year) and 14 PAUs (50%, median 0.4 mm/year). Symptomatic presentation (P = 0.045), connective tissue disorders (P = 0.005), and initial aortic diameter >42 mm (P = 0.013) were associated with AD growth rate. PAU depth >9 mm (P = 0.047) and female sex (P = 0.013) were associated with aortic growth rate in PAUs and IMHs. At 10 years, freedom from disease progression was 22% (95% CI 12-41) for ADs, 44% (95% CI 22-92) for IMHs, and 46% (95% CI 27-78) for PAUs. DeBakey I/IIIB AD (HR 3.09; P = 0.038), initial IMH aortic diameter (HR 1.4; P = 0.037) and PAU depth >10 mm (HR 3.92; P = 0.018) were associated with disease progression. No AD spontaneously resolved; resolution rate at 10 years was 22% (95% CI 0-45) for IMHs and 11% (95% CI 0-23) for PAUs.

CONCLUSIONS

Aortic growth and clinical disease progression are observed in most patients with aortic syndromes, while spontaneous resolution is uncommon. Predictors of aortic growth and disease progression may be used to tailor appropriate follow-up and eventual early intervention.

Combined thoracic endovascular aortic repair and endovascular aneurysm repair and the long-term consequences of altered cardiovascular haemodynamics on morbidity and mortality: case series and literature review

Background

Thoracic and abdominal aortic stent grafts are firmer and more rigid than the native aorta. Aortic implanted devices have been implicated in the development of acute systolic hypertension, elevated pulse pressure, and reduced coronary perfusion.

Case summary

We report four cases of staged thoracic endovascular aortic repair (TEVAR) and then endovascular aneurysm repair (EVAR). All patients had TEVAR first for thoracic aortic aneurysm and later on developed infra-renal abdominal aortic aneurysm (AAA) that required EVAR. There were three males and one female with a median age of 74.5 years (range 67.5-78.5). None of the patients developed aortic-related major clinical adverse effects or required any aortic intervention during their follow-up. However, within 2 years, all patients developed symptomatic left ventricular hypertrophy with diastolic dysfunction. All patients had bilateral lower limb oedema, with on and off chest pain and shortness of breath (SOB), necessitating coronary angiograms, which showed no evidence of coronary artery disease. Three patients died from cardiovascular-related morbidities, and the fourth patient is still complaining of SOB despite a normal coronary angiogram.

Discussion

Aortic-endograft compliance mismatch is an invisible enemy, with troubling consequences for the aorta proximal and distal to the endograft. Aortic stiffness due to vascular endograft could lead to cardiovascular adverse events, even in the absence of direct aortic-related complications. After combined TEVAR and EVAR, the compliance mismatch and elasticity loss are even more pronounced than with TEVAR alone, which necessitates patient monitoring for the development of cardiovascular complications.

Prevalence, Clinical Features, and In-hospital Outcome of Fatty Liver Disease in Acute Aortic Dissection: A Single-Center Retrospective Study

Background and Aims: Fatty liver disease (FLD) has emerged as a major public issue in China. We aim to investigate prevalence, clinical features, and in-hospital outcome of FLD in acute aortic dissection (AAD) patients.

Methods: Data of 379 AAD patients from 2017 to 2019 at Renmin hospital of Wuhan University was retrospectively collected and divided according to age and FLD absence. Propensity score matching was used for minimal confounding. We compared their physical environmental parameter of onset, clinical features, and in-hospital outcome.

Results: The mean age was 52.0 ± 11.5 years in type A and 55.1 ± 11.4 in type B. 25.0% of type A and 19.2% of type B AAD patients had FLD. Logistic regression indicated a negative association between FLD and age, both in type A [unadjusted odds ratio (OR) 0.958 (per 1 year), 95% confidence interval (CI) 0.930–0.988, p = 0.0064] and type B [unadjusted OR 0.943 (per 1 year), 95% CI 0.910–0.978, p = 0.0013]. After matching, type A with FLD had onset with a lower air quality index (AQI) of 68.5 [interquartile range (IQR) 46.0–90.0] and a lower Pm 2.5 concentration of 36.0 μg/m³ (IQR 23.0–56.0) compared with non-FLD group. In Kaplan-Meier estimation, FLD was associated with higher risk of in-hospital mortality in type B AAD (p = 0.0297).

Conclusion: The prevalence of FLD in AAD decrease with age, both in type A and type B AAD. Type A AAD patients with FLD had onset with better air quality parameters compared with non-FLD group. FLD was associated with higher risk of in-hospital mortality in type B AAD.

The characteristics of distal tears affect false lumen thrombosis rate after thoracic endovascular aortic repair for acute type B dissection

OBJECTIVES

A low false lumen thrombosis rate (FLTR) is common in patients with type B aortic dissection after they have undergone thoracic endovascular aortic repair, which indicates a poor long-term prognosis. This study aimed to establish a quantitative linear regression model to predict false lumen (FL) thrombosis accurately using morphological parameters.

METHODS

In this retrospective study, we included 59 patients diagnosed with acute type B aortic dissection between 2014 and 2017. Morphological parameters were measured. Univariable and multivariable linear regression analyses were performed, and a linear regression model relating FLTR with the number of re-entry tears was proposed. Ten patients were further chosen to validate the linear relationship, and idealized aortic dissection models were adopted for haemodynamic analysis.

RESULTS

Only the total area and number of re-entry tears were negatively correlated with FL thrombosis (P < 0.001). Moreover, based on the univariable regression, the number of re-entry tears played a more crucial role in FLTR (R2 = 0.509 vs R2 = 0.298), and the linear relationship model was created as follows: thrombosis rate (%) = -11.25 × distal tear number + 105.24. This model was perfectly matched in 10 patients (concordance correlation coefficient = 0.880, P = 0.947). Moreover, when the total area of re-entry tears was constant, the net blood flow increased rapidly with an increase in the tear count.

CONCLUSIONS

The number of re-entry tears could be a crucial related factor of FL thrombosis; the larger the number of re-entry tears is, the lower the possibility of thrombosis is.

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.