The Effect of Intravenous and Oral Beta-Blocker Use in Patients with Type B Thoracic Aortic Dissection

BACKGROUND

Beta-blockers have become the cornerstone for medical management in patients with chronic type B aortic dissection (TBAD). However, the effect of being on and/or receiving intravenous beta-blockers during hospitalization on outcomes of surgical repair of TBAD is not fully described. We sought to investigate this association during open surgical repair (OSR) and endovascular (Endo) intervention for nontraumatic TBAD.

METHODS

The Premier Healthcare Database was inquired (June/2009-March/2015). Patients with nontraumatic isolated TBAD were identified via ICD-9-CM diagnosis and procedural codes. Patients with codes that indicated TAAD were excluded. In-hospital mortality, cardiac complications (CHF, MI, arrythmia) and stroke were evaluated. Log binomial regression analyses with bootstrapping were performed to assess the relative risk of adverse outcomes.

RESULTS

A total of 1,752 were admitted for OSR (54.3%) and Endo (45.7%) TBAD repair. Use of oral beta blocker (BB) was 16.0% in OSR and 56.4% in Endo groups. In each arm, patients on BB were more likely to be diabetic, on aspirin or statin and more likely to receive additional IV BB than nonBB patients. There was no significant difference in age, sex, race, or prior history of CHF between BB and nonBB groups. Mortality was proportionally lower in patients on BB in OSR group (7.9% vs. 16.7%; P = 0.006) and Endo (3.3% vs. 9.2%; P < 0.001). The adjusted relative risk for mortality and stroke were significantly lower in oral BB recipients compared with none [aRR (95% CI): 0.53 (0.32-0.90) and 0.46 (0.25-0.87); both P ≤ 0.02]. IV metoprolol was the only IV BB that reduced mortality [aRR (95% CI): 0.62 (0.46-0.85); P = 0.003]. A dose of ≤10 mg was associated with significant mortality reduction: 6.3% (3.0-9.5%) compared with 8.1% (4.6-11.6%) in no IV BB group. Cardiac complications were not affected by BB use.

CONCLUSIONS

For patients with nontraumatic TBAD, use of oral BB was associated with significant protection against in-hospital mortality and stroke following repair. Metoprolol was the only Intravenous BB type associated with improved survival. Further research is warranted to elucidate the effect of beta-blockers on the long-term surgical outcomes of TBAD.

A Systematic Review and Meta-analysis of the Incidence of Acute Aortic Dissections in Population-Based Studies

OBJECTIVE

To perform a systematic-review and meta-analysis of all population-based studies reporting on incidence of acute aortic dissections.

METHODS

We searched MEDLINE, EMBASE, CENTRAL and Open Grey databases from inception to August 2020 for population-based studies reporting on the incidence of AAD. A systematic review was conducted following the PRISMA guidelines using a registered protocol (CRD42020204007). Data was pooled using a random-effects model of proportions using Freeman-Tukey double arcsine transformation. The main outcome was the incidence of AAD. Secondary outcomes were incidence type A aortic dissections (TAAD) and type B aortic dissections (TBAD); incidence of aortic dissection repair and medical management and incidence of in-hospital mortality. In addition, we estimated the proportion of aortic dissection repair and mortality (in hospital, overall and specific mortality according to sub-type) among patients with AAD.

RESULTS

Thirty-three studies were included. The pooled incidence of AADs was 4.8 per 100 000 individuals/year (95%CI: 3.6; 6.1). Incidence of TAAD was 3.0 per 100 000/year (95%CI: 1.8; 4.4) and incidence of TBAD was 1.6 per 100 000/year (95%CI: 1.1; 2.2). The incidence of AAD needing repair was 1.4 per 100 000/year (95%CI: 1.0; 2.0) [1.4 (95%CI: 1.2; 1.7) for TAAD and 0.4 (95%CI: 0.2; 0.7) for TBAD]. Incidence of medically managed AAD was 3.4 per 100 000/year (95%CI: 2.4; 4.5). Incidence of in-hospital death due to AAD was 1.3 per 100 000 individuals/year (95%CI: 0.9; 1.9); 1.0 (95%CI: 0.6; 1.4; I²97%) for TAAD and 0.3 for TBAD (95%CI: 0.2; 0.4; I²96%).

CONCLUSION

A global estimate regarding the incidence rate of acute aortic dissections was achieved. Incidence of acute aortic dissection varied significantly between study designs and geographical regions. More accurate information on acute aortic dissection epidemiology is crucial for public-health decisions, clinical understanding, and healthcare management.

Evaluation of Common Carotid Stiffness via Echo Tracking in Hypertensive Patients Complicated by Acute Aortic Dissection

OBJECTIVES

To evaluate the common carotid stiffness via echo tracking in patients with hypertension and acute aortic dissection (AD) and to investigate the independent predictors for the occurrence of AD in hypertensive (HP) patients.

METHODS

Fifty HP patients complicated by acute AD (AD group), 50 HP patients without AD (HP group), and 50 age-matched healthy volunteers (control group) were enrolled to assess the common carotid stiffness index (β), single-point pulsed wave velocity (PWVβ), and arterial compliance (AC) via echo tracking.

RESULTS

The intima-media thickness, diameter, β and PWVβ of the common carotid artery (CCA) in the AD group were significantly higher than those in the HP and control groups, whereas AC in the AD group was significantly lower (P < .05). In a multivariate logistic regression analysis, the systolic blood pressure (SBP; odds ratio [OR], 2.316; 95% confidence interval [CI], 2.033-2.563; P < .001), β (OR, 2.140; 95% CI, 1.931-2.367; P < .001), PWVβ (OR, 1.212; 95% CI, 1.004-1.397; P = .023), and AC (OR, 0.565; 95% CI, 0.339-0.654; P < .001) were significantly related to the occurrence of AD in HP patients. The area under the curve values for the AC, SBP, β, and PWVβ were 0.822, 0.806, 0.778, and 0.741, respectively, and the area under the curve was up to 0.943 when these parameters were combined.

CONCLUSIONS

The compliance of the CCA decreased, and the stiffness of the CCA increased significantly in HP patients complicated by AD. The AC, β, and PWVβ of the CCA, together with the SBP, were independent predictors of the occurrence of AD in HP patients.

Epidemiological Analysis of 5,595 Procedures of Endovascular Correction of Isolated Descending Thoracic Aortic Disease Over 12 Years in the Public Health System in Brazil

OBJECTIVES

In Brazil, descending thoracic aorta disease, including aneurysms and dissections, is managed preferentially by endovascular treatment, owing to its feasibility and good results. In this study, we analyzed endovascular treatment of isolated descending thoracic aortic disease cases in the Brazilian public health system over a 12-year period.

METHODS

Public data from procedures performed from 2008 to 2019 were extracted using web scraping techniques to assess procedure type frequency (elective or urgency), mortality, and governmental costs.

RESULTS

A total of 5,595 procedures were analyzed, the vast majority of which were urgent procedures (61.82% vs. 38.18%). In-hospital mortality was lower for elective than for urgent surgeries (4.96 vs.10.32% p=0.008). An average of R$16,845.86 and R$20,012.04 was paid per elective and emergency procedure, respectively, with no statistical difference (p=0.095).

CONCLUSION

Elective procedures were associated with lower mortality than urgent procedures. There was no statistically significant difference between elective and urgent procedures regarding costs.

Malperfusion-associated transient monoplegia as an initial manifestation of aortic dissection

Acute aortic dissection (AD) is a life-threatening emergency. The most common symptom of AD is chest pain, more frequently associated with Type-A AD per the Stanford classification, while Type-B AD is associated with back and abdominal pain. Conversely, monoplegia is an uncommon symptom of AD. We encountered a case of transient monoplegia caused by Stanford type-B AD. A 75-year-old man presented with acute-onset lumbar back pain with monoplegia. Lumbar radiography revealed multiple compression fractures and spinal-canal stenosis, and accordingly acute spinal-cord compression was suspected. Monoplegia subsided after a diclofenac suppository was administrated to reduce his pain. However, the patient's right lower-extremity pain and paralysis worsened at rest during the stay. Computer tomography angiography revealed Stanford type-B AD and the false lumen obstructing the right common iliac artery. Monoplegia in type-B AD can develop due to spinal-cord or lumbosacral-plexus ischemia. Malperfusion, determined by the balance of the pressure in the false and true lumens and subsequent end-organ ischemia, may produce transient or persistent symptom patterns. Emergency physicians need to suspect AD when a patient presents with monoplegia or transient symptom patterns of unknown etiology.

Incidence of acute type A aortic dissection in emergency departments

Due to the symptoms, patients with acute type A aortic dissection are first seen by the ambulance service and diagnosed at the emergency department. How often an aortic dissection occurs in an emergency department per year has been studied. The incidence in the emergency department may be used as a quality marker of differential diagnostics of acute chest pain. A multi-institutional retrospective study with the municipal Berlin hospital chain Vivantes and its Department of Pathology and the Charité - University Medicine Berlin was performed. From the Berlin Hospital Society, the annual numbers of publicly insured emergency patients were obtained. Between 2006 and 2016, 631 aortic dissections were identified. The total number of patients treated in the emergency departments (n = 12,790,577) was used to calculate the “emergency department incidence.” The autopsy data from six clinics allowed an estimate on how many acute type A aortic dissections remained undetected. Across all Berlin hospitals, the emergency department incidence of acute type A aortic dissection was 5.24 cases in 100,000 patients per year. In tertiary referral hospitals and, particularly, in university hospitals the respective incidences were markedly higher (6.7 and 12.4, respectively). Based on the autopsy results, about 50% of the acute type A aortic dissection may remain undetected, which would double the reported incidences. Among different hospital types the emergency department incidences of acute type A aortic dissection vary between 5.93/100,000 and 24.92/100,000. Aortic dissection; Incidence; Emergency Department; Epidemiology

Systematic review and meta-analysis of acute type B thoracic aortic dissection, open, or endovascular repair

OBJECTIVE

The purpose of this study was to compare perioperative and mortality outcomes of endovascular aortic repair against open repair in acute type B thoracic aortic dissection.

METHODS

A comprehensive search was undertaken among the four major databases (PubMed, Embase, Scopus, and Ovid) to identify all published data comparing open vs endovascular repair in management of acute type B aortic dissection. Databases where evaluated and assessed to July 2017. The 95% confidence intervals were analyzed from the extracted data using relevant statistical methods.

RESULTS

Overall, 18,193 patients were found in a combination of nine studies. Patients undergoing open repair were younger (mean, 61.3 ± 9.3 years vs 66.6 ± 12.5 years; P < .00001). Postoperative stroke and paraplegia were similar in both groups (P = .71 and P = .81 respectively); however, the rate of all neurologic complications were more common in the traditional open repair group (6.9% vs 4.8%; P = .006). The all-cause operative and 1-year death was reported as higher in the open repair group (18.6% vs 7.4% [P < .0001] and 24.3% vs 14.3% [P < .0001], respectively); however, at 5 years this rate is almost similar between both groups (46.7% vs 49.7%; P = .21). At 1 year, the rate of reintervention was reported to be higher in endovascular repair group of patients (15.4% vs 5.5%; P = .004).

CONCLUSIONS

This study concludes that endovascular repair, in the setting of acute type B thoracic aortic dissection, provides an early surgical benefit; however, this finding has not yet been supported by long-term data. There seems to be a benefit with respect to all-neurologic events in favor of endovascular repair. Long-term comparative data and studies are required to give a better understanding of these two approaches.

Protocol for the ROBUST (Registry Of type B aortic dissection with the Utility of STent graft) study: an ambispective, multicentre, open cohort study

INTRODUCTION

Thoracic endovascular aortic repair (TEVAR) is widely used for type B aortic dissection, although with satisfactory outcome in a limited proportion of patients. To better inform patient prognostication, the Registry Of type B aortic dissection with the Utility of STent graft (ROBUST) study aims to identify imaging-based predictors of post-TEVAR adverse outcomes up to 10-year follow-up.

METHODS AND ANALYSIS

ROBUST is designed as an ambispective, multicentre, open cohort study. All patients undergoing TEVAR from 1 January 2008 to 1 July 2027 at participating centres will be invited to join the study. It is conservatively estimated that over 2000 patients will join the study. Data on demographics, disease history, procedural details, imaging features and follow-up will be collected after discharge. Cox proportional-hazards analysis will be used to identify independent predictors of primary outcomes. Stratification analysis will be performed to identify which subgroup of patients would benefit the most from TEVAR.

ETHICS AND DISSEMINATION

The protocol has been approved by the ethics committee of the coordinating centre. Findings will be disseminated in professional peer-reviewed journals to promote understanding of the rehabilitation process.

TRIAL REGISTRATION NUMBER

ChiCTR-POC-17011726; Pre-results.

Safety and Feasibility Study of a Novel Stent-Graft for Thoracic Endovascular Aortic Repair: a Canine Model Experiment

Objective

To evaluate the safety and feasibility of a novel stent-graft for thoracic endovascular aortic repair (TEVAR) in a canine model, 9 adult hybrid dogs were used for the experiment.

Methods

All animals were implanted with a novel thoracic aortic stent-graft via femoral artery. Blood sample was collected at pre-operation and 1, 2, 4, 8 and 12 weeks after implantation for hematological examination. Moreover, tissues from randomly selected 4 dogs were subjected to histopathological analysis with the optical microscope after stent-grafts were implanted for 3, 6, 9, and 12 months respectively. The experimental period lasted for more than 2 years.

Results

A total of 9 stent-grafts were successfully implanted in the canine thoracic aortas and no migration or deformation occurred. Related indicators of blood routine, inflammatory factors, and immunology changes were not significantly (P>0.05), except the white blood cell (WBC) counts in the first week. Moreover, abnormal morphology was not found in all thoracic aortas via histopathological examination. Additionally, all stent-grafts were patent and did not migrate, and there was no thrombus in the lumens of stent-grafts.

Conclusion

The novel thoracic aortic stent-graft made in China was safe and feasible for thoracic endovascular aortic repair in a canine model.

Epidemiology and Medication Utilization Pattern of Aortic Dissection in Taiwan: A Population-Based Study

Acute aortic dissection (AD) is a catastrophic condition associated with a high rate of mortality. However, current epidemiological information regarding AD remains sparse. The objective of the present study was to investigate the current epidemiological profile and medication utilization patterns associated with aortic dissection in Taiwan.In this population-based study, we identified cases of AD diagnosed during 2005 to 2012 in the complete Taiwan National Health Insurance (NHI) Research Database. Patients with AD were identified using the International Classification of Disease, Ninth Revision (ICD-9) code 441.0, and surgical interventions were defined using NHI procedure codes.A total of 9092 individuals with a mean age of 64.4 ± 15.1 years were identified. The cases were divided into 3 groups: Group A included 2340 patients (25.74%) treated surgically for type A AD; Group B included 1144 patients (12.58%) treated surgically for type B AD, and Group C included 5608 patients (61.68%) with any type of AD treated with medical therapy only. The average annual incidence of AD was 5.6 per 100,000 persons, and the average prevalence was 19.9 per 100,000 persons. Hypertension was the most common risk factor, followed by coronary artery disease and chronic obstructive pulmonary disease. Within 1 year of AD diagnosis, 92% of patients were taking antihypertensive medication. Calcium channel blockers were the most frequently prescribed antihypertensive medication for long-term observation in Taiwan.The annual trends revealed statistically significant increases in the numbers and percentages of prevalence, incidence, and mortality. Changes in patients' drug utilization in patterns were observed after AD diagnosis. Our study provides a local profile that supports further in-depth analyses in AD-affected populations.

Pyrexia in patients with uncontrolled systemic hypertension: could they have an aortic dissection?

Aortic dissection can present in a variety of ways and one of the most documented risk factors includes systemic hypertension. Occasionally aortic dissection can be diagnosed late due to an insidious presentation. Fever has been described in people with aortic dissection but rarely as the main presenting feature. We present the cases of two patients with type B aortic dissections who shared three pertinent features which could have alerted the clinicians of the potential diagnosis; systemic hypertension, small left sided pleural effusion and a fever of unknown origin.

Increasing prevalence of hypertension among patients with thoracic aorta dissection: trends over eight decades--a structured meta-analysis

BACKGROUND

This structured metaanalysis focused on determining the relationship between hypertension (HTN) and thoracic aortic dissection (TAD).

METHODS

Electronic searches were conducted using the MedLine database, for the period 1946 through May 2013, and manual searches from reference lists. Demographic data, patient diagnosis, and HTN prevalence were extracted from each study. Data were analyzed using weighted averages, metaanalysis, analysis of variance, trend analysis, and multivariate analysis.

RESULTS

A total of 8,086 cases of TAD from 75 studies over eight decades were assessed. Overall prevalence of HTN in TAD was 66.7% ± 17.5%. An increase of approximately 5.6% in HTN prevalence in TAD cases occurred in every decade. Prevalence of HTN in type A dissections steadily increased, with an overall prevalence of 64.8% ± 21.3%, while in type B dissections, prevalence abruptly increased from 1950 to 1970 and remained constant thereafter, with an overall prevalence of 78.7% ± 8.6%. Trend analysis demonstrated significant (P < 0.001) and linear increasing trends for the prevalence of HTN and age at presentation. Multivariate analysis demonstrated that a history of HTN was significantly (P < 0.001) associated with increasing trends of over time, which was independent of the relationship between age and TAD.

CONCLUSIONS

The proportion of TAD patients with HTN has been increasing over eight decades. Age at presentation of TAD has also been incrementally increasing, but the increase in HTN was independent of age in multivariate analysis. The trend for increasing HTN prevalence was more evident in type A TAD. These data highlight a need to focus on HTN management in patients with thoracic aortic aneurysm.

Combined surgical treatment in aortic type A dissection

Acute Stanford type A aortic dissection is a fatal event that, for its high mortality when left untreated, requires urgent surgical intervention. The established treatment includes repair of the ascending aorta and various portions of the aortic arch, leaving the descending aorta untreated. We report the case of a 62-year-old man in whom a combined approach of the ascending aorta with surgical correction and transluminal placement of a stent in the aortic arch was performed.

Endovascular stent-grafts treatment in acute aortic dissection (type B): Clinical outcomes during early, late, or chronic phases

OBJECTIVE

This is a prospective study to evaluate the clinical outcomes of endovascular repair in patients with different phases of type B aortic dissection.

BACKGROUND

Endovascular repairing with stent-grafts is an innovative technique for type B acute aortic dissection. There is no previous study regarding outcomes in different time phases.

METHODS

Sixty-two patients underwent endovascular stent-grafts. There were 23 in the early phase (<24 hr), 20 in the late phase (>or=24 hr to 2 weeks), and 19 in the chronic phase (>2 weeks).

RESULTS

The early phase group had the lowest ratio of stent-grafts to patient and the shortest stent-graft length. The chronic phase group had the largest diameter of false lumen. The technical success rate was 100%; no patient died within hospital. Three patients died within 30 days, with the same death rate in every group. Compared with acute patients, the chronic group had a higher volume of contrast, a higher creatinine post-procedure, and a higher incidence of contrast-induced nephropathy. Multiple regression analysis demonstrated that creatinine and endoleak were independent factors in predicting late death (95% CI, 3.4-26%, P < 0.01). The overall cardiovascular event-free survival was 88.9% +/- 2.1% at 30 days, 87.2% +/- 4.1% at 1 year, and 81.4% +/- 6.3% at 2 years. CT angiography identified the complete or partial thrombosis of the false lumen to be 95.7%.

CONCLUSIONS

Endovascular repairing with stent-graft is safe, feasible, and able to treat type B aortic dissection in all phases. However, chronic renal dysfunction was an independent factor which contributed to a lower survival rate of chronic phase patients.