Prognosis for Patients With Type B Acute Aortic Dissection Risk Analysis of Early Death and Requirement for Elective Surgery

A multicenter clinical trial on the five-year outcomes following treatment of acute, complicated type B aortic dissection with a conformable stent graft

OBJECTIVE

Thoracic endovascular repair (TEVAR) has become the treatment of choice for acute, complicated type B aortic dissections. The purpose of this study was to evaluate the 5-year outcomes of the GORE TAG 08-01 study on TEVAR for acute, complicated type B aortic dissections using the Conformable GORE® TAG® Thoracic Endoprosthesis (CTAG), and to establish if late aortic complications are avoided and remodeling is sustained.

METHODS

From January 2010 to February 2017, 50 patients with acute, complicated type B aortic dissections were enrolled from 26 sites in the U.S. in this prospective, non-randomized study. Patients underwent follow-up assessments post-procedure, at 1 month, 6 months, 1 year and then yearly through 5 years. Device-related events, false lumen thrombosis, and aortic remodeling were assessed from computed tomography (CT) scans by a core laboratory.

RESULTS

The all-cause mortality rate through 5 years was 26%. 4% of patients experienced late (> 30 day) deaths that were attributable to aortic pathology. Secondary interventions were required in 22% of patients. In 87% of patients complete false lumen thrombosis in the portion of the false lumen parallel to the stent graft was observed. There was a significant 11 mm increase in maximum true lumen diameter (P < .0001) and a 22 mm decrease in maximum false lumen diameter (P < .0001), over 5 years. True lumen area was also increased, by 221 mm2 (P = .0003) over 5-years. There was no significant change in false lumen area. There were no associations observed between patient outcomes and pre-treatment indication for treatment (i.e., rupture with or without malperfusion or malperfusion alone).

CONCLUSIONS

Treatment of patients with advanced pathophysiology with the CTAG device resulted in favorable long-term clinical and anatomic outcomes. Complete thrombosis of the false lumen and positive aortic remodeling was sustained throughout the study. The low rate of late aortic events observed in this study demonstrates the safety, effectiveness and the long-term durability of the CTAG device.

Successful factors for improving aortic remodeling with thoracic endovascular repair and bare stent extension

OBJECTIVE

Proximal ExTension to Induce COmplete ATtachment (PETTICOAT), which uses downstream bare metal stents for structural support, demonstrates potential, yet its adoption is limited by variable outcomes. This study elucidates the potential of PETTICOAT in aortic dissection, emphasizing the determinants that guide patient selection.

METHODS

A retrospective analysis of 60 patients who underwent full PETTICOAT for aortic dissections was conducted. A multivariate logistic regression model identified predictors of favorable aortic remodeling. Patients underwent standardized follow-up with computed tomography scans to assess size, volumetric changes, and anatomical conditions. Selection criteria included full PETTICOAT application and a minimum of 3 months of follow-up. Demographics, preoperative conditions, and procedural details were collected and analyzed.

RESULTS

The analysis identified predictors of favorable aortic remodeling, including age >60 years, a larger downstream aorta stent graft, a smaller abdominal aorta (<450 mm2), and oral angiotensin II receptor blocker administration. Over a median 47.5 months of follow-up, survival rates in the favorable remodeling (97.3%) and unfavorable groups (100%) were similar. Downstream aortic event-free survival rates did not differ significantly (89.2% vs 73.9%), although the unfavorable group had a relatively higher incidence of distal stent-induced new entries (26.1% vs 8.1%).

CONCLUSIONS

The PETTICOAT concept effectively enhances aortic remodeling in complex aortic dissections. Predictors for favorable remodeling, including age, stent graft sizing, aortic diameter, and angiotensin II receptor blocker therapy, offer insights for optimizing patient selection. This approach improves survival outcomes, mitigates risks associated with untreated aortic segments, and provides a minimally invasive solution for aortic dissections. Despite some outcome variations, the technique holds promise for addressing the challenges of aortic dissections, with the potential for further refinement in patient selection and technique application.

Thoracic Endovascular Aortic Repair on Zone 2 Landing for Uncomplicated Type B Aortic Dissection with Measurement of Intra-False Lumen Pressure

BACKGROUND

This study aimed to evaluate the midterm results of zone 2 thoracic endovascular aortic repair (TEVAR) for uncomplicated type B aortic dissection (TBAD) by measuring the intra-false lumen pressure (IFLP) during TEVAR.

METHODS

Fifteen patients (9 men; mean age, 57 years) who underwent zone 2 TEVAR for uncomplicated TBAD were reviewed. Delta systolic pressure (defined as the difference between systemic pressure and IFLP) was measured before and after primary entry closure, and aortic remodeling and thrombo-occlusion of the false lumen (FL) were evaluated 12 months after TEVAR at 5 different levels of the aorta.

RESULTS

Median duration from onset to TEVAR was 34 days. The left subclavian artery was preserved in 13 patients (87%) by using stent graft fenestration. Although 1 patient (6%) had a transient cerebral infarction, there were no severe TEVAR-related complications. Entry closure significantly reduced delta systolic pressure (mm Hg) compared to preoperative pressure at all levels (distal arch: -22.2 ± 10.8 vs. -5.2 ± 9.6; Th8: -20.1 ± 12.4 vs. -6.9 ± 7.2; Th10: -14.3 ± 14.6 vs. -4.7 ± 7.5; Th12: -14.4 ± 14.5 vs. -4.9 ± 7.8; L2: -14.5 ± 14.2 vs. -3.4 ± 6.9). The percentages of aortic remodeling with expansion of the true lumen (distal arch: 82%; Th8: 80%; Th10: 54%; Th12: 45%; L2: 50%) and complete false lumen thrombosis (distal arch: 100%; Th8: 100%; Th10: 67%; Th12: 11%; L2: 0%) were approximately consistent with the change in delta systolic pressure. During a follow-up of 41 months, distal stent-induced new entry occurred in 2 patients (13%) requiring secondary intervention; however, there were no cases of FL enlargement or aorta-related mortality.

CONCLUSIONS

Zone 2 TEVAR for uncomplicated TBAD may prevent TEVAR-related complications. Measuring IFLP could be a new predictive marker for assessing the extent of aortic remodeling.

Reinterventions after TEVAR

Thoracic cardiovascular aortic repair is an alternative procedure to open surgery for degenerative thoracic aortic aneurysm and thoracic aortic dissection. The advancements in graft design and imaging techniques have expanded its utility. However, the long-term patency of thoracic endovascular aortic repair (TEVAR) graft is still a concern. This review delves into the literature on re-intervention following TEVAR, highlighting factors that influence the re-intervention rate.

Preoperative Predictors of Late Aortic Expansion in Acute Type B Aortic Dissection Treated with TEVAR

BACKGROUND

A patent false lumen (FL) in patients with thoracic endovascular aortic repair (TEVAR)-treated type B aortic dissection (TBAD) can cause a significant risk for late aortic expansion (LAE). We hypothesize that preoperative features can predict the occurrence of LAE.

METHODS

Sufficient preoperative and postoperative follow-up clinical and imaging feature data for patients treated with TEVAR in the First Affiliated Hospital of Nanjing Medical University from January 2018 to December 2020 were collected. A univariate analysis and multivariable logistic regression analysis were used to find potential risk factors of LAE.

RESULTS

Ninety-six patients were finally included in this study. The mean age was 54.5 ± 11.7 years and 85 (88.5%) were male. LAE occurred in 15 (15.6%) of 96 patients after TEVAR. Two preoperative factors showed strong associations with LAE according to the multivariable logistic regression analysis: preoperative partial thrombosis of the FL (OR = 10.989 [2.295-48.403]; p = 0.002) and the maximum descending aortic diameter (OR = 1.385 [1.100-1.743] per mm increase; p = 0.006).

CONCLUSIONS

Preoperative partial thrombosis of the FL and an increase in the maximum aortic diameter are strongly associated with late aortic expansion. Additional interventions of the FL may help to improve the prognosis of patients with the high risk of late aortic expansion.

Genetic Variation in LRP1 Associates with Stanford Type B Aortic Dissection Risk and Clinical Outcome

Genetic variation in LRP1 (low-density lipoprotein receptor-related protein 1) was reported to be associated with thoracic aortic dissections and aneurysms. The aims of this study were to confirm this association in a prospective single-center patient cohort of patients with acute Stanford type B aortic dissections (STBAD) and to assess the impact of LRP1 variation on clinical outcome. The single nucleotide variation (SNV) rs11172113 within the LRP1 gene was genotyped in 113 STBAD patients and 768 healthy control subjects from the same population. The T-allele of rs11172113 was more common in STBAD patients as compared to the reference group (72.6% vs. 59.6%) and confirmed to be an independent risk factor for STBAD (p = 0.002) after sex and age adjustment in a logistic regression model analyzing diabetes, smoking and hypertension as additional risk factors. Analysis of clinical follow-up (median follow-up 2.0 years) revealed that patients with the T-allele were more likely to suffer aorta-related complications (T-allele 75.6% vs. 63.8%; p = 0.022). In this study sample of STBAD patients, variation in LRP1 was an independent risk factor for STBAD and affected clinical outcome.

Differences in the clinical presentation, management, and in-hospital outcomes of acute aortic dissection in patients with and without end-stage renal disease

Background

Few studies have evaluated the clinical presentation, management, and outcomes of patients with end-stage renal disease (ESRD) presenting with acute aortic dissection (AAD) in real-world clinical practice. Thus, this study investigated the clinical characteristics, management, and outcomes of AAD patients with ESRD.

Methods

A total of 217 patients were included. We evaluated the differences in the clinical features, management, and in-hospital outcomes of patients with and without a history of ESRD presenting with AAD.

Results

A history of ESRD was present in 71 of 217 patients. Patients with ESRD had atypical clinical manifestations (p < 0.001) and were more likely to be managed medically compared with patients without ESRD (p = 0.002). Hypertension and type B aortic dissection were significantly more common among patients with ESRD. Moreover, patients with ESRD had lower leucocyte and platelet counts than patients without ESRD in laboratory findings (p < 0.001). However, hospitalization days and in-hospital mortality were similar between the two groups (p > 0.05). Multivariate analysis identified Type A aortic dissection as an independent predictor of in-hospital mortality among patients without ESRD (OR, 13.68; 95% CI, 1.92 to 98.90; P = 0.006).

Conclusions

This study highlights differences in the clinical characteristics, management, and outcomes of AAD patients with ESRD. These patients usually have atypical symptoms and more comorbid conditions and are managed more conservatively. However, these patients have no in-hospital survival disadvantage over those without ESRD. Further studies are needed to better understand and optimize care for patients with ESRD presenting with AAD.

Current evidence in predictors of aortic growth and events in acute type B aortic dissection

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.

Quantitative Study of Abdominal Blood Flow Patterns in Patients with Aortic Dissection by 4-Dimensional Flow MRI

The purpose of this study is to evaluate the hemodynamic characteristics of the true lumen (TL) and the false lumen (FL) in 16 patients with aortic dissection (AD) using 4D flow magnetic resonance imaging (MRI) and thoracic and abdominal computed tomography (CT) angiography. The quantitative parameters that were measured in the TL and FL included velocity and flow. The mean area and regurgitant fraction of the TL were significantly lesser at all four levels (p < 0.05); the average through-plane velocity, peak velocity magnitude, average net flow, peak flow, and net forward volume in the TL were considerably higher (p < 0.05). The intimal entry's size was negatively correlated with the blood flow velocity and flow rate in the TL (p < 0.05) and positively correlated with the average through-plane velocity, average net flow, and peak flow in the FL (p < 0.05); the blood flow indices in the TL were enhanced with an increase in the intimal entry numbers (p < 0.05) and the peak flow in the FL was lowered (p = 0.025); if FL thrombosis existed, the average through-plane velocity and peak velocity magnitude in the TL were substantially higher (p < 0.05). 4D flow MRI facilitates qualitative and quantitative analysis of the alterations in the abdominal aortic blood flow patterns.

Incidence and risk factors of recurrent pain in acute aortic dissection and in-hospital mortality

BACKGROUND

We investigated the prevalence of recurrent pain and its relationship with in-hospital mortality in acute aortic dissection (AAD).

PATIENTS AND METHODS

Between 2011 and 2016, 234 AAD patients were selected. Recurrent pain was defined as a mean of VAS > 3, within 48 hours following hospital admission or before emergency operation. Patients with and without recurrent pain were divided into group I and group II, respectively into type A AAD and type B AAD patients. Our primary outcome was in-hospital mortality.

RESULTS

The incidence of recurrent pain was 24.4 % in AAD patients. Incidence of recurrent pain was higher in type A AAD patients than type B AAD patients (48.9 vs. 9.6 %). Overall in-hospital mortality was 25.6 %. Type A AAD had a higher in-hospital mortality than type B AAD patients (47.7 vs. 12.3 %). Group I had significantly higher in-hospital mortality than group II (type A: 79.1 vs. 17.8 %; type B: 57.1 vs. 7.6 %, all P < 0.001), as was the case with medical managed patients (type A: 72.1 vs. 13.3 %; type B: 35.7 vs. 2.3 %, all P < 0.001). Logistic regression analysis showed that use of one drug alone and waist pain were predictive factors for recurrent pain in type A AAD and type A AAD patients, respectively (OR 3.686, 95 % CI: 1.103~12.316, P = 0.034 and OR 14.010, 95 % CI: 2.481~79.103, P = 0.003). Recurrent pains were the risk factors (type A: OR 11.096, 95 % CI: 3.057~40.280, P < 0.001; type B: OR 14.412, 95 % CI: 3.662~56.723, P < 0.001), while invasive interventions were protective (type A: OR 0.133, 95 % CI: 0.035~0.507, P < 0.001; type B: OR 0.334, 95 % CI: 0.120~0.929, P = 0.036) for in-hospital mortality in AAD patients.

CONCLUSIONS

Approximately one-fourth of AAD patients presented with recurrent pains, which might increase in-hospital mortality. Thus, interventional strategies at early stages are important.

Outcomes of Thoracic Endovascular Aortic Repair for Acute Type B Dissection in Patients With Intractable Pain or Refractory Hypertension

PURPOSE

To compare uncomplicated acute type B aortic dissection (UATBAD) patients with intractable pain/refractory hypertension treated with thoracic endovascular aortic repair (TEVAR) to UATBAD subjects without these features receiving best medical therapy (BMT).

METHODS

Interrogation of the hospital database identified 101 consecutive UATBAD patients admitted between January 2011 and December 2014. Of these, 74 patients (mean age 62±13 years; 44 men) were treated with BMT; the other 27 UATBAD patients (mean age 63±13 years; 17 men) were subsequently treated with TEVAR for intractable pain (24, 89%) and/or refractory hypertension (3, 11%) at a mean 2.4±3.3 days (median 1, range 0-12) after admission. Mixed models were employed to determine differences in centerline measured aortic remodeling. Propensity analysis was employed to mitigate selection bias. Kaplan-Meier methodology was used to estimate reintervention and survival.

RESULTS

The groups were well matched; there was no difference in demographics, comorbidities, or proportion with visceral involvement (70% for TEVAR vs 86% for BMT, p=0.08). There was no significant difference in length of stay (9.6±6.3 for TEVAR vs 10.3±7.8 for BMT, p=0.3), complications (19% for TEVAR vs 24% for BMT, p=0.6), or 30-day mortality (0 for TEVAR vs 7% for BMT, p=0.1). One (4%) TEVAR patient experienced retrograde dissection. BMT resulted in greater mean increase in discharge antihypertensive medications (1.7±1.9 vs 0.7±1.7 for TEVAR, p=0.03), but there was no difference in narcotic utilization. Mean follow-up was greater in the TEVAR group (17.9±16.0 months) compared with BMT patients (11.5±10.8 months, p=0.05). TEVAR significantly improved rates of aortic diameter change (1.5% vs 12.9% for BMT, p=0.007), complete false lumen thrombosis (41% vs 11% for BMT, p=0.004), and true lumen expansion (85% vs 7% for BMT, p<0.01). However, there was no difference in reintervention (25.9% for TEVAR vs 23% for BMT, p=0.2) or survival (log-rank p=0.8).

CONCLUSION

TEVAR for UATBAD with intractable pain/refractory hypertension is safe but offers no short-term outcome advantage when compared to UATBAD patients without these features receiving BMT. A significant improvement in aortic remodeling was identified after TEVAR. The potential long-term reintervention and aorta-related mortality benefits of this favorable remodeling have yet to be defined and randomized trials are warranted.

New type A dissection after acute type B aortic dissection

OBJECTIVE

Aortic dissection is a dynamic process that can progress both proximal and distal to the initial entry tear. We sought to determine associations for development of proximal progression or new type A aortic dissection (NTAD) after acute type B dissection (ATBD) and its effect on survival of the patient.

METHODS

We reviewed all cases of acute aortic dissection that we managed from 1999 to 2014. Univariate and bivariate analyses were performed to identify correlates of NTAD. Multivariable regression and proportional hazards regression analysis was done to determine the effect of dissection progression on long-term survival.

RESULTS

Among 477 cases of ATBD managed, 19 (4.0%) patients developed NTAD during a median follow-up of 4.1 (interquartile range, 1.4-7.7) years. Median time from diagnosis of ATBD to NTAD was 124 (interquartile range, 23-1201) days. Baseline predictors for development of NTAD at initial ATBD admission included bicuspid aortic valve (P = .006) and age <60 years (P = .012). Although not statistically significant, point estimates indicate that thoracic endovascular aortic repair was twice as frequent in NTAD cases as in non-NTAD cases. Overall 5-year survival was 70.2%. Patients who had repair of NTAD appear to have longer survival, although this effect is on the margin of statistical significance (P = .051). After risk factor and correlates of NTAD adjustment, this effect was no longer apparent (P = .089).

CONCLUSIONS

The natural history of ATBD is such that there is a persistent risk of NTAD, with the highest risk in the first 6 months. Factors associated with NTAD include bicuspid aortic valve and young age. Thoracic endovascular aortic repair did not have a large effect on risk. Timely diagnosis and repair of NTAD are associated with good survival rates. Lifelong surveillance is warranted in all cases of descending thoracic aortic dissection regardless of initial treatment modality.

Treatment of serious complications following endovascular aortic repair for type B thoracic aortic dissection

Objective

This study aimed to describe treatment of serious complications after primary thoracic endovascular aortic repair (TEVAR) in type B aortic dissection.

Methods

From June 2008 to March 2016, serious complications occurred in 58 patients without Marfan syndrome who received TEVAR for type B aortic dissection.

Results

Complications included endoleak, distal true lumen collapse, retrograde dissection, stroke, stent–graft (SG) migration and mistaken deployment, lower limb ischaemia, and SG fracture. Treatment included endovascular repair, surgical procedures, or conservative medication. Forty-six patients recovered from complications. Twelve patients were not cured. The median follow-up time was 29.5 months (2–61 months). The overall 30-day mortality rate was 1.7% (1/58) and the total mortality rate following secondary complications was 8.6% (5/58). The causes of death were stroke and aortic rupture.

Conclusion

Some treatments need to be performed after TEVAR because of severe complications. A reduction in these complications can be achieved by optimal evaluation of patients, selection of SGs, and specialized endovascular manipulation.

Prognostic significance of early aortic remodeling in acute uncomplicated type B aortic dissection and intramural hematoma

BACKGROUND

Patients with Stanford type B aortic dissections (ADs) are at risk of long-term disease progression and late complications. The aim of this study was to evaluate the natural course and evolution of acute type B AD and intramural hematomas (IMHs) in patients who presented without complications during their initial hospital admission and who were treated with optimal medical management (MM).

METHODS

Databases from 2 aortic centers in Europe and the United States were used to identify 136 patients with acute type B AD (n = 92) and acute type B IMH (n = 44) who presented without complications during their index admission and were treated with MM. Computed tomography angiography scans were available at onset (≤14 days) and during follow-up for those patients. Relevant data, including evidence of adverse events during follow-up (AE; defined according to current guidelines), were retrieved from medical records and by reviewing computed tomography scan images. Aortic diameters were measured with dedicated 3-dimensional software.

RESULTS

The 1-, 2-, and 5-year event-free survival rates of patients with type B AD were 84.3% (95% confidence interval [CI], 74.4-90.6), 75.4% (95% CI, 64.0-83.7), and 62.6% (95% CI, 68.9-73.6), respectively. Corresponding estimates for IMH were 76.5% (95% CI, 57.8-87.8), 76.5% (95% CI, 57.8-87.8), and 68.9% (95% CI, 45.2-83.9), respectively. In patients with type B AD, risk of an AE increased with aortic growth within the first 6 months after onset. A diameter increase of 5 mm in the first half year was associated with a relative risk for AE of 2.29 (95% CI, 1.70-3.09) compared with the median 6 months' growth of 2.4 mm. In approximately 60% of patients with IMH, the abnormality resolved within 12 months and in the patients with nonresolving IMH, risk of an adverse event was greatest in the first year after onset and remained stable thereafter.

CONCLUSIONS

More than one third of patients with initially uncomplicated type B AD suffer an AE under MM within 5 years of initial diagnosis. In patients with nonresolving IMH, most adverse events are observed in the first year after onset. In patients with type B AD an early aortic growth is associated with a greater risk of AE.

Admission Values of D-dimer and C-reactive Protein (CRP) Predict the Long-term Outcomes in Acute Aortic Dissection

Objective Admission D-dimer and C-reactive protein (CRP) values have been reported to predict the short-term outcomes in acute aortic dissection (AAD). However, the association between D-dimer values and the long-term outcomes has not been investigated. Methods The primary endpoints included events determined to be all-cause death, recurrence of aortic dissection, aortic rupture, and surgical intervention for the aortic aneurysm following the first hospital discharge. We performed a receiver operating characteristic analysis and determined the optimal cut-off levels of admission D-dimer, admission CRP and peak CRP values in terms of the sensitivity and specificity for predicting the presence of events. Using the optimal cut-off values, we performed a multiple Cox analysis and investigated the hazard ratio of admission D-dimer, admission CRP and peak CRP. Patients We retrospectively identified 173 AAD patients hospitalized between January 2005 and December 2013. Results A multiple Cox regression analysis revealed that the hazard ratios were 3.4 for admission D-dimer [95% Confidence Interval (CI) 1.5 to 7.3, p=0.004] and 2.7 for admission CRP (95% CI 1.2 to 5.5, p=0.014). Conclusion Admission D-dimer and CRP values may predict the long-term outcomes in AAD. Moreover, admission D-dimer values may be a valuable marker to predict not only the short-term outcomes, but also the long-term outcomes in AAD.

Outcomes of Open Surgical Repair for Type B Dissecting Aortic Aneurysm With Alternative Methods in the Endovascular Stent Era

We assessed the midterm outcomes of 2 types of open surgical repair for type B dissecting aortic aneurysm (BDA). During the last 4 years, 86 patients with BDA (mean age, 68.5 ± 9.8 years; range: 41-87 years) underwent open repair. The average duration between the dissection onset and surgery was 51.5 ± 31.3 months. If the BDA was of open type with patent false lumen or the aneurysm extended for a long segment, descending or thoracoabdominal aortic repair was performed with left thoracotomy. If the BDA was of the closed type with thrombosed false lumen and the aneurysm was located around the distal arch, open stent implantation was performed with our unique technique using circulatory arrest with a rectal temperature of 28 °C without any cerebral perfusion. Left thoracotomy was performed in 68 patients. The durations of aortic clamping and cardiopulmonary bypass were 65.2 ± 16.9 and 78.5 ± 34.6 minutes, respectively. Open stent implantation was performed in 18 patients. The durations of circulatory arrest and cardiopulmonary bypass were 19.1 ± 5.1 and 86.2 ± 17.8 minutes, respectively. In the present study, 4 patients (4.7%) required reexploration for bleeding and 1 patient (1.2%) had a stroke, but none suffered paraplegia. The hospital mortality rate was 1.2% (1 patient), resulting from retrograde type A dissection. The actuarial aortic event-free survival rate, including operative death, was 96.4% at 3 years. Both open surgical procedures for BDA were relatively safe, with favorable early and midterm outcomes, and may be superior for avoiding neurologic complications.

Mid-term outcomes and aortic remodelling after thoracic endovascular repair for acute, subacute, and chronic aortic dissection: the VIRTUE Registry

OBJECTIVE

The VIRTUE Registry describes the mid-term clinical and morphological results of thoracic endovascular repair (TEVR) in patients with type B aortic dissection.

METHODS

This was a prospective cohort study. The VIRTUE Registry is a prospective, multicentre clinical trial that enrolled patients with complicated acute (<15 days), subacute (15-92 days), and chronic (>92 days) type B aortic dissections treated with the Valiant endograft. One hundred patients were enrolled and the clinical outcomes described at the 3-year follow-up. Analysis of the aortic area and false lumen thrombosis rates defined the morphological response to TEVR in the three clinical groups.

RESULTS

Three-year all-cause mortality (18%, 4%, and 24%), dissection related mortality (12%, 4%, and 9%), aortic rupture (2%, 0%, and 4%), retrograde type A dissection (5%, 0%, and 0%), and aortic reintervention rates (20%, 22%, and 39%) were, respectively, defined for patients with acute (n = 50), subacute (n = 24), and chronic (n = 26) dissections. Analysis of aortic morphology observed that patients with subacute dissection demonstrated a similar degree of aortic remodelling to patients with acute dissection. Patients with acute and subacute dissection exhibited greater aortic plasticity than patients with chronic dissection.

CONCLUSIONS

The principle clinical findings suggest that TEVR is able to provide good protection from aortic-related death in the mid-term, but with a high rate of aortic reintervention. Analysis of aortic morphology suggested that aortic remodelling in subacute patients is similar to the acute group. Retention of aortic plasticity in the subacute group lengthens the therapeutic window for the treatment of uncomplicated type B dissection.

Impact of acute kidney injury on in-hospital outcomes in patients with DeBakey type III acute aortic dissection

The relation between the incidence and severity of acute kidney injury (AKI) and clinical outcomes remains unclear in patients with DeBakey type III acute aortic dissection (AAD). We retrospectively assessed 56 patients admitted to our hospital for type III AAD within 48 hours of the onset of symptoms. The presence of AKI was identified, and its severity was staged on the basis of changes in serum creatinine (SCr) levels within 7 days after admission. We investigated the relations between AKI and clinical presentations, in-hospital complications, and predischarge renal function; AKI was observed in 20 patients (36%). After adjusting for age, gender, and body mass index, the incidence of AKI was associated with a history of hypertension, electrocardiographic ST-T changes, DeBakey type IIIb, and SCr level on admission. Maximum white blood cell count and serum C-reactive protein level were higher in patients with AKI than in those without AKI. AKI was associated with a greater incidence of in-hospital complications (70% vs 39%, p = 0.03) and higher SCr levels at discharge (1.1 [range 1.0 to 2.0] vs 0.9 [range 0.7 to 1.0] mg/dl, p = 0.0001). These associations were more pronounced in patients with relatively severe AKI. Multivariate analysis revealed that SCr level on admission and DeBakey type IIIb with renal artery involvement were major predictors of AKI. In conclusion, renal function on admission and renal artery involvement were significant risk factors for AKI, which was associated with poor outcomes and enhanced inflammatory response during hospitalization in patients with type III AAD.

Long-Term Outcome of Aortic Dissection With Patent False Lumen

Background—

Patent false lumen in aortic dissection has been associated with poor prognosis. We aimed to assess the natural evolution of this condition and predictive factors.

Methods and Results—

One hundred eighty-four consecutive patients, 108 surgically treated type A and 76 medically treated type B, were discharged after an acute aortic dissection with patent false lumen. Transesophageal echocardiography was performed before discharge, and computed tomography was performed at 3 months and yearly thereafter. Median follow-up was 6.42 years (quartile 1 to quartile 3: 3.31–10.49). Forty-nine patients died during follow-up (22 type A, 27 type B), 31 suddenly. Surgical or endovascular treatment was indicated in 10 type A and 25 type B cases. Survival free from sudden death and surgical-endovascular treatment was 0.90, 0.81, and 0.46 (95% CI, 0.36–0.55) at 3, 5, and 10 years, respectively. Multivariate analysis identified baseline maximum descending aorta diameter (hazard ratio [HR]: 1.32 [1.10–1.59]; P =0.003), proximal location (HR: 1.84 [1.06–3.19]; P =0.03), and entry tear size (HR: 1.13 [1.08–1.2]; P <0.001) as predictors of dissection-related adverse events, whereas mortality was predicted by baseline maximum descending aorta diameter (HR: 1.36 [1.08–1.70]; P =0.008), entry tear size (HR: 1.1 [1.04–1.16]; P =0.001), and Marfan syndrome (HR: 3.66 [1.65–8.13]; P =0.001).

Conclusions—

Aortic dissection with persistent patent false lumen carries a high risk of complications. In addition to Marfan syndrome and aorta diameter, a large entry tear located in the proximal part of the dissection identifies a high-risk subgroup of patients who may benefit from earlier and more aggressive therapy.

Re-elevation of D-dimer as a predictor of re-dissection and venous thromboembolism after Stanford type B acute aortic dissection

D-dimer measurement is a useful complementary initial diagnostic marker in patients with acute aortic dissection (AAD). However, it has not been clarified whether serial measurements of D-dimer are useful during in-hospital management of Stanford type B AAD. We studied 30 patients who were admitted with diagnosis of Stanford type B AAD and treated conservatively. D-dimer was serially measured on admission and then every 5 days during hospitalization. Patients were divided into two groups according to the presence or absence of re-elevation of D-dimer during hospitalization, in which D-dimer transition were biphasic and latter peak >10.0 μg/ml. Re-elevation of D-dimer was observed in 17 patients. There were no differences in atherosclerotic risk factors, blood pressure on admission, D-dimer level on admission, extent of AAD, and false lumen patency. Patients with re-elevation of D-dimer showed higher incidence of re-dissection and/or venous thromboembolism (VTE). Peak D-dimer level in patients with re-dissection and/or VTE was significantly higher than that without these complications (p = 0.005). In conclusion, serial measurements of D-dimer are useful for early detection of re-dissection or VTE in patients with Stanford type B AAD, which may contribute to the prevention of disastrous consequences such as pulmonary embolism and extension of AAD.

Importance of Refractory Pain and Hypertension in Acute Type B Aortic Dissection

Background—

In patients with acute type B aortic dissection, presence of recurrent or refractory pain and/or refractory hypertension on medical therapy is sometimes used as an indication for invasive treatment. The International Registry of Acute Aortic Dissection (IRAD) was used to investigate the impact of refractory pain and/or refractory hypertension on the outcomes of acute type B aortic dissection.

Methods and Results—

Three hundred sixty-five patients affected by uncomplicated acute type B aortic dissection, enrolled in IRAD from 1996 to 2004, were categorized according to risk profile into 2 groups. Patients with recurrent and/or refractory pain or refractory hypertension (group I; n=69) and patients without clinical complications at presentation (group II; n=296) were compared. “High-risk” patients with classic complications were excluded from this analysis. The overall in-hospital mortality was 6.5% and was increased in group I compared with group II (17.4% versus 4.0%; P =0.0003). The in-hospital mortality after medical management was significantly increased in group I compared with group II (35.6% versus 1.5%; P =0.0003). Mortality rates after surgical (20% versus 28%; P =0.74) or endovascular management (3.7% versus 9.1%; P =0.50) did not differ significantly between group I and group II, respectively. A multivariable logistic regression model confirmed that recurrent and/or refractory pain or refractory hypertension was a predictor of in-hospital mortality (odds ratio, 3.31; 95% confidence interval, 1.04 to 10.45; P =0.041).

Conclusions—

Recurrent pain and refractory hypertension appeared as clinical signs associated with increased in-hospital mortality, particularly when managed medically. These observations suggest that aortic intervention, such as via an endovascular approach, may be indicated in this intermediate-risk group.

Midterm outcomes of rapid, minimally invasive resection of acute type A aortic dissection in octogenarians

BACKGROUND

We previously reported the development of a new surgical technique, called the "less invasive quick replacement" technique, for treating type A acute aortic dissection. This study examines the midterm outcome and postoperative quality of life of octogenarian patients who underwent less invasive quick replacement.

METHODS

During the last 3 years, 27 patients underwent less invasive quick replacement. The average age of the patients at the time of onset was 81.7 years old. During open distal anastomosis with a rectal temperature of 28 degrees C without any cerebral perfusion, circulating blood in the cardiopulmonary bypass circuit was warmed to 40 degrees C. As soon as the distal anastomosis was completed, rapid rewarming was initiated by 40 degrees C blood perfusion. We assessed the midterm outcomes in terms of survival and cardiovascular event-free rates, patency of the distal false lumen, aortic regurgitation, and cognitive disorders.

RESULTS

The durations of circulatory arrest, cardiopulmonary bypass, overall operation, postoperative mechanical ventilation, and hospital stay were 18.7 minutes, 82.8 minutes, 143.4 minutes, 13.0 hours, and 12.2 days, respectively. Hospital mortality rate was 3.7% (1 patient). There were no incidences of brain damage, renal failure, or respiratory failure. At the time of this study, 25 of the patients were doing well and visiting the outpatient clinic, and 22 of them scored more than 20 points on the Mini-Mental State Examination, indicating no development of dementia. Midterm computed tomography scans detected the patent false lumen in 11.5%. No aortic regurgitation was found in the echocardiography. Actuarial survival and cardiovascular event-free rates at 3 years were 96.2% and 83.0%, respectively.

CONCLUSIONS

The less invasive quick replacement technique is safe and effective. It is a very attractive option that can contribute to maintaining a long-term good quality of life for octogenarians with type A acute aortic dissection.

Peak C-Reactive Protein Level Predicts Long-Term Outcomes in Type B Acute Aortic Dissection

Acute aortic dissection (AAD) is associated with an inflammatory reaction, as evidenced by elevated inflammatory markers, including C-reactive protein (CRP). The association between the peak CRP level and long-term outcomes in type B AAD has not been systematically investigated. The purpose of this study was to investigate whether the peak CRP level during admission predicts long-term outcomes in type B AAD. We conducted a clinical follow-up study of type B AAD. We divided the study population into 4 groups according to the tertiles of peak CRP levels (T1: 0.60 to 9.37 mg/dL; T2: 9.61 to 14.87 mg/dL; T3: 14.90 to 32.60 mg/dL; and unavailable peak CRP group). Multivariate Cox regression analysis was applied to investigate whether the tertiles of peak CRP predict adverse events even after adjusting for other variables. A total of 232 type B AAD patients were included in this analysis. The median follow-up period was 50 months. CRP reached its peak on day 4.5±1.7. Mean peak CRP values in T1, T2, and T3 were 6.4±2.4, 12.0±1.5, and 19.5±4.0 mg/dL, respectively. There were 65 events (39 deaths and 26 aortic events) during the follow-up. T3 and T2 (versus T1) were strong predictors of adverse events (T3: hazard ratio: 6.02 [95% CI: 2.44 to 14.87], P =0.0001; T2: hazard ratio: 3.25 [95% CI: 1.37 to 7.71], P =0.01) after controlling for all of the confounding factors. In conclusion, peak CRP is a strong predictor for adverse long-term events in patients with type B AAD.

Determinants of long-term mortality in patients with type B acute aortic dissection

BACKGROUND

Type B acute aortic dissection (AAD) carries a high short- and midterm mortality rate; however, knowledge related to long-term outcome is largely incomplete. The objective of this study was to identify long-term predictors including antihypertensive medications in type B AAD.

METHODS

We conducted a clinical follow-up study on 202 type B AAD patients. Univariate and multivariate Cox regression analyses were performed to identify predictors of mortality.

RESULTS

There were 44 postdischarge deaths in 202 consecutive type B AAD patients with a median follow-up of 55 months. In univariate Cox regression analysis, age (10 year incremental: hazard ratio (HR) 1.82, 95% confidence interval (CI) 1.35-2.46, P < 0.0001), previous myocardial infarction or angina pectoris (HR 3.93, 95% CI 1.72-8.99, P = 0.001), and impaired renal function (HR 4.90, 95% CI 2.48-9.65, P < 0.0001) were predictors of death. Calcium channel blockers (CCBs), beta-blockers, and angiotensin-converting enzyme (ACE) inhibitors as antihypertensive medications at discharge were predictors of increased survival. In multivariate Cox regression analysis, CCBs were a significant predictor of increased survival (vs. no antihypertensive medication at discharge: HR 0.38, 95% CI 0.15-0.97, P = 0.04). Impaired renal function was a significant predictor of death (HR 3.41, 95% CI 1.58-7.33, P = 0.002). No antihypertensive medication at discharge group was significantly associated with increased mortality (vs. 1 class of antihypertensive medication: HR 9.51, 95% CI 1.85-48.79, P = 0.007).

CONCLUSIONS

Impaired renal function was a predictor for adverse outcome in patients with type B AAD. The use of CCBs as antihypertensive medication at discharge was associated with increased survival.

Retrograde type A aortic dissection after endovascular stent graft placement for treatment of type B dissection

BACKGROUND

Retrograde type A aortic dissection has been deemed a rare complication after endovascular stent graft placement for type B dissection. However, this life-threatening event appears to be underrecognized and is worth being investigated further.

METHODS AND RESULTS

Eleven of 443 patients developed retrograde type A aortic dissection during or after stent grafting for type B dissection from August 2000 to June 2007. Of these 11 patients, 3 had Marfan syndrome. The Kaplan-Meier estimate of the rate of freedom from this event at 36 months is 97.4% (95% confidence interval, 0.95 to 0.99). The new entry was located at the tip of the proximal bare spring of the stent graft in 9 patients, was within the anchoring area of the proximal bare spring in 1, and remained unknown in 1 patient. Eight patients were converted to open surgery, and 2 received medical treatment. One patient suddenly died 2 hours after the primary stent grafting, and 2 died within 1 week after the surgical conversion, so mortality reached 27.3%. During the follow-up from 3 to 50 months, type I endoleak was identified in 1 patient 3 months after the surgical exploration and disappeared at 6 months.

CONCLUSIONS

Retrograde type A aortic dissection after stent grafting for type B dissection appears not to be rare and results from mixed causes. Fragility of the aortic wall and disease progression may predispose to it, whereas stent grafting-related factors make important and provocative contributions. Avoiding aortic arch stent grafting in Marfan patients, preferably selecting the endograft without the proximal bare spring for patients with a kinked aortic arch or with Marfan syndrome (if endografting is used), improving the device design, and standardizing endovascular manipulation might lessen its occurrence.

Risk factors for prolonged mechanical ventilation following surgery for acute type a aortic dissection

BACKGROUND

The aim of this study was to identify predictors of prolonged mechanical ventilation (PMV) following surgery for acute type A aortic dissection (AAAD) and to assess the influence of this complication on clinical outcomes.

METHODS AND RESULTS

A total of 243 patients underwent emergency surgery for AAAD in the period of 1997-2006. Ten patients died within 48 h after surgery. The remaining 233 patients were divided into 2 groups according to the duration of mechanical ventilation; less than 48 h (group A: n=149) or 48 h or longer (group B; n=84). Multivariate analysis was used to identify predictors of PMV. Short and late outcomes were compared between groups. Multivariate analysis showed that shock (systolic BP <90 mmHg; p=0.007), postoperative renal dysfunction (creatinine >2.0 mg/dl; p=0.016), coronary artery bypass grafting (CABG) (p=0.017), and limb ischemia (p=0.044) were independent predictors of PMV. There was no significant difference in in-hospital mortality (group A, 2.7% vs group B, 3.6%) or 5-year survival (group A, 85.9% vs group B, 76.8%).

CONCLUSIONS

Shock, limb ischemia, CABG, and postoperative renal dysfunction increase the risk for PMV. Knowing the predictors of PMV should help optimize postoperative management of these patients.

Acute aortic dissection

We summarise advances in the epidemiology, presentation, pathogenesis, diagnosis, and management of acute aortic dissection. Improved understanding of this problem has been assisted not only by establishment of an international registry but also by progress in molecular biology and genetics of connective-tissue diseases. Advances in endovascular products and techniques have provided new treatment options. Open surgical repair remains the main treatment for dissection in the ascending aorta, whereas endovascular treatment is increasingly being used in dissection that is limited to other parts of the aorta.