Association Between Preoperative Monocyte to High-Density Lipoprotein Ratio on In-hospital and Long-Term Mortality in Patients Undergoing Endovascular Repair for Acute Type B Aortic Dissection

Uncomplicated Type B Aortic Dissection: Challenges in Diagnosis and Categorisation

BACKGROUND

Acute type B aortic dissection (TBAD) is a rare disease that is likely under-diagnosed in the UK. As a progressive, dynamic clinical entity, many patients initially diagnosed with uncomplicated TBAD deteriorate, developing end-organ malperfusion and aortic rupture (complicated TBAD). An evaluation of the binary approach to the diagnosis and categorisation of TBAD is needed.

METHODS

A narrative review of the risk factors predisposing patients to progression from unTBAD to coTBAD was undertaken.

RESULTS

Key high-risk features predispose the development of complicated TBAD, such as maximal aortic diameter > 40 mm and partial false lumen thrombosis.

CONCLUSION

An appreciation of the factors that predispose to complicated TBAD would aid clinical decision-making surrounding TBAD.

Coronary artery disease as an independent predictor of short-term and long-term outcomes in patients with type-B aortic dissection undergoing thoracic endovascular repair

Background and aims

Previous studies reported a high prevalence of concomitant coronary artery disease (CAD) in patients with Type B aortic dissection (TBAD). However, there is too limited data on the impact of CAD on prognosis in patients with TBAD. The present study aimed to assess the short-term and long-term impact of CAD on patients with acute or subacute TBAD undergoing thoracic endovascular aortic repair (TEVAR).

Methods

We retrospectively evaluated 463 patients with acute or subacute TBAD undergoing TEVAR from a prospectively maintained database from 2010 to 2017. CAD was defined before TEVAR by coronary angiography. Multivariable logistic and cox regression analyses were performed to evaluate the relationship between CAD and the short-term as well as long-term outcomes.

Results

According to the results of coronary angiography, the 463 patients were divided into the following two groups: CAD group (N = 148), non-CAD group (N = 315). In total, 12 (2.6%) in-hospital deaths and 54 (12%) all-cause deaths following a median follow-up of 48.1 months were recorded. Multivariable analysis revealed that CAD was an independent predictor of in-hospital major adverse clinical events (MACE) (odd ratio [OR], 2.33; 95% confidence interval [CI], 1.07-5.08; p = 0.033), long-term mortality [hazard ratio (HR), 2.11, 95% CI, 1.19-3.74, P = 0.011] and long-term MACE (HR, 1.95, 95% CI, 1.26-3.02, P = 0.003). To further clarify the relationship between the severity of CAD and long-term outcomes, we categorized patients into three groups: zero-vessel disease, single-vessel disease and multi-vessel disease. The long-term mortality (9.7 vs. 14.4 vs. 21.2%, P = 0.045), and long-term MACE (16.8 vs. 22.2 vs. 40.4%, P = 0.001) increased with the number of identified stenosed coronary vessels. Multivariable analysis indicated that, multi-vessel disease was independently associated with long-term mortality (HR, 2.38, 95% CI, 1.16-4.89, P = 0.018) and long-term MACE (HR, 2.79, 95% CI, 1.65-4.73, P = 0.001), compared with zero-vessel disease.

Conclusions

CAD was associated with short-term and long-term worse outcomes in patients with acute or subacute TBAD undergoing TEVAR. Furthermore, the severity of CAD was also associated with worse long-term prognosis. Therefore, CAD could be considered as a useful independent predictor for pre-TEVAR risk stratification in patients with TBAD.

Risk profile analysis of uncomplicated type B aortic dissection patients undergoing thoracic endovascular aortic repair: Laboratory and radiographic predictors

BACKGROUND

There is emerging evidence to support pre-emptive thoracic endovascular aortic repair (TEVAR) intervention for uncomplicated type B aortic dissection (unTBAD). Pre-emptive intervention would be particularly beneficial in patients that have a higher baseline risk of progressing to complicated TBAD (coTBAD). There remain debate on the optimal clinical, laboratory, morphological, and radiological parameters, which would identify the highest-risk patients that would benefit most from pre-emptive TEVAR.

AIM

This review summarizes evidence on the clinical, laboratory, and morphological parameters that increase the risk profiles of unTBAD patients.

METHODS

A comprehensive literature search was carried out on multiple electronic databases including PubMed, EMBASE, Ovid, and Scopus to collate all research evidence on the clinical, laboratory, and morphological parameters that increase the risk profiles of unTBAD patients RESULTS: At present, there are no clear clinical guidelines using risk-stratification to inform the selection of unTBAD patients for TEVAR. However, there are noticeable literature trends that can assist with the identification of the most at-risk unTBAD patients. Patients are at particular risk when they have refractory pain and/or hypertension, elevated C-reactive protein (CRP), larger aortic diameter, and larger entry tears. These risks should be considered alongside factors that increase the procedural risk of TEVAR to create a well-balanced approach. Advances in biomarkers and imaging are likely to identify more pertinent parameters in the future to optimize the development of balanced, risk-stratified treatment protocols.

CONCLUSION

There are a variety of risk profiling parameters that can be used to identify the high-risk unTBAD patient, with novel biomarkers and imaging parameters emerging. Longer-term evidence verifying these parameters would be ideal. Further randomized controlled trials and multicentre registry analyses are also warranted to guide risk-stratified selection protocols.