Acute Aortic Dissection in Young Adult Patients: Clinical Characteristics, Management, and Perioperative Outcomes

Quality of life in young patients with acute type a aortic dissection in China: comparison with Marfan syndrome and non-Marfan syndrome

BACKGROUND

There is a paucity of Chinese studies evaluating the quality of life (QoL) in young acute type A aortic dissection (AAAD) patients with Marfan syndrome.

METHODS

Young adult AAAD patients (younger than 45 years old) underwent surgical treatment at our institution from January 2017 to December 2020 were consecutive enrolled. The hospital survivors completed 1 year of follow up. Patients were divided into two groups according to the presence or absence of Marfan syndrome (MFS). A 1:1 propensity score matching (PSM) with a caliper 0.2 was conducted to balance potential bias in baseline. The follow-up data were analyzed primarily for change in quality of life and anxiety status.

RESULTS

After PSM, 32 comparable pairs were matched. The baseline data were comparable and postoperative complications were similar between groups. In terms of SF-36 scale, the role physical, bodily pain, role emotional and mental health subscales were no significantly improved in MFS patients over time. At 1 year after discharged, the subscale of mental health and bodily pain were significantly lower in the MFS group than in the non-MFS group. In terms of HADS assessments, the level of anxiety in MFS patients was significantly higher than in non-MFS patients at 1 year after discharged.

CONCLUSIONS

The QoL in young AAAD patients with MFS is lower than those without MFS after surgery. This may be associated with the uncontrollable persistent chronic pain and the uncertainty and concerns for the disease's progression.

Type A acute aortic dissection presenting as a stroke in a young male patient

A male patient in his 40s with a history of nephrolithiasis and found in the desert after 10 days without oral intake was admitted to the hospital for severe dehydration, acute kidney injury and rhabdomyolysis. He had acute-onset loss of consciousness during hospitalisation with new left-sided hemiparesis and hemineglect. After haemorrhage was excluded, prompt thrombolysis was given. He later had chest pain and became hypotensive. An echocardiogram revealed pericardial effusion and dilation of the ascending aorta with suspected dissection. Magnetic resonance angiography of the brain and neck reported bilateral parieto-occipital areas of stroke in a watershed distribution and dissection of the right internal carotid artery. CT angiography showed type A aortic dissection from the ascending aorta extending into the bilateral common iliac arteries. Thrombolysis was reversed and the patient underwent ascending aorta replacement, resuspension of the aortic valve and aortic arch debranching at outside facility with complete recovery.

Age-related difference in acute type B aortic dissection

OBJECTIVE

The objective is to compare the characteristics of clinical data, imaging data, and treatment methods of young and old patients with acute type B aortic dissection (ABAD).

METHODS

ABAD patients admitted to the Department of Vascular Surgery of the First Affiliated Hospital of Anhui Medical University from January 2012 to December 2018 were retrospectively reviewed. Patient demographics, such as gender, age, diabetes, hypertension, presenting symptoms, imaging characteristics, laboratory data on admission, hemodynamics on admission and in-hospital management, and mortality of different age groups were compared and analyzed. Categorical variables were compared using χ2 tests or Fisher's exact test. Continuous variables were compared using Student's t-test or Mann-Whitney U-test.

RESULTS

A total of 141 ABAD patients were included in this study. Old ABAD patients were more likely to have a prior history of hypertension (88.6% vs 70.4%, p = 0.037) and atherosclerosis (29.8% vs 7.4%, p = 0.016). In the young group, Marfan syndrome was significantly higher (14.8% vs 0.9%; p = 0.005). Compared with the old group, the number of distal tears in the young group was significantly higher (62.3% vs 39.5%, p = 0.027). The proportion of patients with malperfusion of lower limbs in the young group was significantly higher than that in the old group (22.2% vs 6.1%, p = 0.026). There was no significant difference in the treatment methods and in-hospital mortality between the two groups.

CONCLUSION

Compared with old ABAD patients, young ABAD patients had more distal tears and a higher proportion of lower limbs malperfusion.

Comparison of Chimney and Fenestrated Techniques for Supra-Aortic Branch Revascularization During Thoracic Endovascular Aortic Repair: A Systematic Review and Meta-Analysis

PURPOSE

To compare the technical and clinical outcomes of fenestrated thoracic endovascular aortic repair (F-TEVAR) and chimney thoracic endovascular aortic repair (CH-EVAR) of aortic disease.

METHODS

PubMed, Embase and Cochrane databases were systematically searched to identify studies on the management of thoracic aortic pathologies using chimney or fenestrated techniques published between 2000 and 2022. Individual studies provided at least one of the following essential outcomes: technical success, immediate and follow-up type I endoleak, 30-day and aorta-related mortality, cerebral events and supra-aortic branch patency.

RESULTS

24 chimney (1106 patients) and 21 fenestrated technique studies (1040 patients) were included. The scope of the study encompassed various thoracic aortic conditions, such as thoracic aortic dissection, thoracic aortic aneurysm, thoracic aortic ulcer, and other thoracic aortic diseases. Technical success was defined as the handling of the principal ailment affecting the aorta, devoid of any instances of complications. The technical success rates were higher in fenestrated group compared with chimney group (98.0% vs. 95.8% p < 0.001), and the rate of type I endoleak either immediately or during follow-up was higher in the chimney technique group (9.3% vs. 1.3% p < 0.001, 4.0% vs. 0.0% p < 0.001). The chimney technique group had higher 30-day mortality and aorta-related mortality than those in the fenestrated technique group (2.1% vs. 0.3% p < 0.001, 0.4% vs. 0.0% p < 0.001). Morbidity rates of cerebral events and supra-aortic branch patency were same in both groups (2.2% vs. 1.1% p = 0.116, 98.2% vs. 99.4% p = 0.094). The chimney technique group had longer operative time (110.0 min vs. 90.8 min p < 0.001). Two groups had same fluoroscopy time (34.0 min vs. 33.4 min p = 0.614).

CONCLUSIONS

The finding suggest that both the chimney and fenestrated techniques are efficacious in supra-aortic branch reconstruction. However, the fenestrated technique exhibits potential superiority as an interventional strategy, as it demonstrates a lower incidence of type 1 Endoleak, 30-day mortality, and aorta-related death following TEVAR.

Risk Factors Associated with Poor Prognosis in Patients with Stanford Type B Aortic Dissection after Thoracic Endovascular Aortic Repair

BACKGROUND

The aim of the study was to analyze the clinical characteristics of patients with Stanford type B aortic dissection (TBAD) and risk factors for poor prognosis after thoracic endovascular aortic repair (TEVAR).

METHODS

Clinical records for patients with TBAD presenting to a medical center between March 1, 2012 and July 31, 2020 were reviewed. Clinical data including demographics, comorbidities, and postoperative complications were obtained from electronic medical records. Comparative analysis and subgroup analysis were performed. A logistic regression model was used to analyze prognostic factors in patients with TBAD after TEVAR.

RESULTS

TEVAR was performed on all 170 patients with TBAD, and poor prognosis was identified in 28.2% (48/170) of cases. Patients with a poor prognosis were younger (38.5 [32.0, 53.8] years vs. 55.0 [48.0, 62.0] years, P < 0.001), had higher systolic blood pressure (SBP) (138.5 [127.8, 152.8] mm Hg vs. 132.0 [120.8, 145.3] mm Hg, P = 0.013) and more complicated aortic dissection patients (19 [60.4] vs. 71 [41.8], P = 0.029) than those without a poor prognosis. According to the results of binary logic regression analysis, the possibility of a poor prognosis after TEVAR decreased with each 10 years increase in age (odds ratio: 0.464, 95% confidence interval: 0.327-0.658, P < 0.001).

CONCLUSIONS

There is an association between younger age and a poor prognosis after TEVAR in patients with TBAD, with the condition that those with poor prognoses have higher SBP and more complicated cases. In younger patients, postoperative follow-up should be more frequent, and complications should be managed in time.

Does preoperative dual antiplatelet therapy affect bleeding and mortality after total arch repair for acute type A dissection?

OBJECTIVES

Data are scarce and mixed regarding the impact of preoperative dual antiplatelet therapy (DAPT) on the surgical outcomes of acute type A aortic dissection (ATAAD). We seek to evaluate the impact of DAPT on bleeding-related events and early- and mid-term mortality after total arch replacement and frozen elephant trunk in such patients.

METHODS

This study comprised 48 ATAAD patients on preoperative DAPT and 418 without DAPT (the whole series, i.e. unmatched cohort), from which 45 matched pairs were selected by propensity score (matched cohort). Bleeding-related events (reoperation for bleeding, bleeding of ≥1500 ml within the first 12 h postoperatively or transfusion of ≥10 units of red blood cell or use of recombinant activated factor VII), operative mortality and mid-term survival were compared in the unmatched and matched cohorts. The impact of preoperative DAPT was evaluated with multivariable analysis.

RESULTS

In the unmatched cohort, bleeding of ≥1500 ml/12 h postoperatively was more common in the DAPT group (18.8% vs 8.4%, P = 0.020); operative mortality was 9.7%, which did not differ with DAPT (12.5% vs 9.3%, P = 0.48). Nor did bleeding-related events (54.2% vs 43.5%, P = 0.16) differ significantly between 2 groups. In the matched cohort, neither were drainage of ≥1500 ml/12 h (20% vs 6.7%, P = 0.063) and bleeding-related events (53.3% vs 42.2%, P = 0.30), nor operative mortality (13.8 vs 8.9%, P = 0.50) and mid-term survival (79.3% vs 76.4%, P = 0.93) significantly different between 2 groups. DAPT was not identified as a predictor for operative mortality [odd ratio (OR) 0.97, 95% confidence interval (CI) 0.31-3.08; P = 0.96; adjusted OR 1.28, 95% CI 0.22-7.20; P = 0.78] and bleeding-related events (OR 1.50, 95% CI 0.76-2.95; P = 0.24; adjusted OR 2.03, 95% CI 0.80-3.66; P = 0.14).

CONCLUSIONS

In patients with ATAAD undergoing total arch replacement and frozen elephant trunk, although preoperative DAPT led to more postoperative bleeding, it did not increase bleeding-related events nor operative mortality nor mid-term death. The results of this study imply that for patients with ATAAD, emergency surgical repair, even if as extensive as total arch repair, should not be contraindicated or delayed simply because of ongoing DAPT.

Management of acute type A aortic dissection during COVID-19 outbreak: Experience from Anzhen

OBJECTIVES

We seek to report our management protocol and early outcomes of acute type A aortic dissection (ATAAD) repair during the early phase of coronavirus disease 2019 (COVID-19).

METHODS

From January 23 to April 30, 2020, we performed ATAAD repair for 33 patients, including three with pregnancy-related TAADs. Confirmation of COVID-19 depended on the results of two nucleic acid tests and pulmonary computed tomography scan. Based on testing results and hemodynamic stability, patients were triaged to an isolated intensive care unit or negative pressure operating room for emergency surgery.

RESULTS

Mean age 50.2 ± 13.3 years and 20 were male (60.1%) and 8 patients were febrile (>37.3°C; 24.2%) and 17 were lymphopenic (51.5%). No patient was excluded from COVID-19 infection preoperatively. Extensive aortic repair with total arch replacement (TAR) was performed in 24 (72.7%), and limited proximal repair in 9 patients (27.3%). Cardiopulmonary bypass and cross-clamp times averaged 177 ± 34 and 88 ± 20 min for TAR, and 150 ± 30 and 83 ± 18 min for hemiarch, respectively. The mean operation time was 410 ± 68.3 min. Operative mortality was 6.1% (2/33). Complications included reintubation in four (12.1%), acute kidney failure in two (6.1%), and cerebral infarction in one (3.0%). No paraplegia nor re-exploration for bleeding occurred. COVID-19 was excluded in 100% eventually. No nosocomial infection occurred. Nor did any patient/surgical staff develop fever or test positive during the study period.

CONCLUSIONS

The results of this study show that our management protocol based on testing results and hemodynamic stability in patients with ATAAD during the COVID-19 pandemic was effective and achieved favorable early surgical outcomes.

City lockdown and nationwide intensive community screening are effective in controlling the COVID-19 epidemic: Analysis based on a modified SIR model

Background

In December 2019, an outbreak of COVID-19 epidemic occurred in Wuhan, China and infection spread rapidly around the world. To limit the rapid spread locally and nationwide, the Chinese government locked down Wuhan city on January 23 and began implementing nationwide intensive community screening on February 16.

Method

To assess the effectiveness of city lockdown and intensive community screening, we built a modified SIR model by introducing an α value into the classic SIR model. The α value represents the proportion of infected individuals who are not effectively isolated from susceptible individuals at a given time point.

Results

The accuracy of the modified SIR model was validated using data from Guangdong and Zhejiang provinces. The lockdown of Wuhan city substantially reduced the α value for the rest of China excluding Hubei province, while only slightly reducing the α value for the city itself. Intensive community screening rapidly reduced the α value for Wuhan.

Conclusion

City lockdown was efficient in controlling the spread of the epidemic from Wuhan to the rest of the country. Nationwide intensive community screening was extremely effective in suppressing the spread locally within Wuhan city. These experiences should urgently be shared with other countries to help halt the progressing worldwide pandemic.