Late Referral and Patient Transfer is Associated with Worse Outcomes for Patients Presenting with Initially Uncomplicated Type B Aortic Dissections.

BACKGROUND: Acute type B aortic dissections (TBADs) can become complicated at any time point, necessitating surgical repair. We sought to investigate the effect of interhospital transfer on the development of delayed complications in acute type B aortic dissection (dcTBAD). METHODS: All patients who presented with acute TBAD to a tertiary aortic center from 2015 to 2019 were analyzed. Patients were divided into initially complicated type B aortic dissection (icTBAD) (0-24 hours from symptom onset), dcTBAD (25 hours to 14 days), and uncomplicated type B aortic dissection (ucTBAD) groups. Criteria for complicated dissection were aortic rupture, malperfusion, or rapid aortic growth. Demographics, patient history, the timing of presentation, imaging findings, and clinical outcomes were compared between groups. RESULTS: Of 120 acute TBADs included, 27 (22%) were initially complicated (aortic rupture, n = 9; malperfusion, n = 18). Twenty-one (18%) developed delayed complications (aortic rupture, n = 3; malperfusion, n = 14; rapid growth, n = 4) at a median of 7.0 [4.0, 9.0] days from symptom onset. Seventy-two (60%) remained uncomplicated. Overall, 111 (93%) presented as transfers from outside hospitals (icTBAD, n = 25; dcTBAD, n = 21; ucTBAD, n = 65). Of those, dcTBADs were more likely to have a prolonged delay between presentation to the outside hospital and referral to the tertiary center compared to ucTBADs (median = 1.00 [0.0, 5.0] days delayed vs. 0.00 [0.0, 0.0] days delayed; P < 0.001). Initially uncomplicated patients referred for transfer ≥24 hours from presentation went on to develop dcTBAD more often than those transferred in <24 hours (73% vs 13%; P < 0.001). Of dcTBADs, 38% had no high-risk features on initial imaging. Patients with dcTBAD had significantly longer length of stay (median = 12 vs 7 days; P = 0.006). In-hospital mortality was significantly higher in dcTBADs than ucTBADs (9.5% vs 0%; P = 0.047). In-hospital mortality was not significantly different between dcTBADs and icTBADs (9.5% vs. 11%; P > 0.05). CONCLUSIONS: The incidence and consequence of dcTBADsare not insignificant. Late referral and transfer to a tertiary aortic center (≥24 hours from initial presentation) was associated with dcTBADsrequiring surgical intervention. The development of dcTBADwas associated with increased length of stay and increased in-hospital mortality.

Celiac artery occlusion from median arcuate ligament compression complicating a hemorrhagic duodenal ulcer repair.

We present a case of a hemorrhagic duodenal ulcer complicated by occlusion of the celiac artery (CA) by acute median arcuate ligament (MAL) compression. Angiography revealed retrograde flow through the gastroduodenal artery (GDA) to the hepatic artery, with occlusion at the CA origin. This unique presentation required coordinated release of the MAL to reestablish antegrade CA flow before pyloroplasty and GDA ligation. The presence of preexisting MAL compression of the CA should be considered during the repair of bleeding duodenal ulcers through embolization or ligation of the GDA, because impaired CA perfusion could result in foregut ischemia.

Prevalence of intracranial aneurysms in Marfan syndrome.

OBJECTIVE: Aneurysmal pathology of the aorta is well-defined in the Marfan syndrome (MFS) population. Owing in part to the rarity of pathologies, the prevalence of intracranial aneurysms (IA) in MFS is poorly defined. There is debate as to whether or not there is an association between the two. The aim of this study was to evaluate the prevalence of IA in a population of patients with MFS who underwent intracranial imaging. METHODS: This was a single-center retrospective review of patients with MFS. Between 1995 and 2021, 983 patients were reviewed. We identified 198 patients with MFS who had intracranial imaging. Imaging consisted of CTA and/or MRA, and was read by an attending radiologist. Details of the aneurysm, patient demographics, and aortic characteristics were collected. RESULTS: The prevalence of IA was 7.1% (14/198). Age of patients with IA (55.0 ± 15.1 years) was not significantly different than those without IA (52.6 ± 16.0 years) (P = .58). The most common location of IA was the internal carotid artery. The mean diameter of the IA was 7 ± 5.8 mm. No ruptures of the internal carotid artery were identified. One patient (0.5%) underwent intervention for the IA. There were no significant differences found in aortic characteristic including dimensions, history of dissection, or aneurysm. CONCLUSIONS: In a large, single-center experience over 20 years, we identified patients with confirmed MFS who underwent intracranial imaging. The prevalence of IA in our experience was 7.1%. There were no patient or aortic characteristics found to be significantly associated with IA; however, this finding may be due to the small number of aneurysms. Although this number is higher than the historically reported prevalence in the general population, a collection of experiences from multiple institutions will likely be required to truly define the risk of IA in MFS and to determine whether screening is warranted.

Racial disparities in presentation and short-term outcomes for patients with acute type B aortic dissection.

OBJECTIVE: Racial disparities in cardiovascular risk factors and disease outcomes have been well documented. A knowledge gap exists regarding the role that health maintenance plays in the development and outcomes of type B aortic dissection (TBAD). In the present study, we evaluated the comparative presentation and short-term outcomes of patients with TBAD across race. METHODS: In the present single-center, retrospective study, TBAD patients who had been admitted to the intensive care unit from 2015 to 2020 were identified. Patients who had self-identified as Black (n = 57) or White (n = 123) were included. The demographics, socioeconomic status, and pre-event health maintenance were compared between the two groups. Socioeconomic disadvantage was quantified using the area deprivation index (ADI). Management strategies included nonoperative and surgical repair. The outcomes assessed included 30-day mortality, hospital length of stay, and the APACHE II (acute physiology and chronic health evaluation) score. RESULTS: The present study included 180 consecutive patients with TBAD. TBAD included complicated (n = 42) and uncomplicated (n = 138) cases, of which 79 had had high-risk features. Black patients were younger than were White patients (58.9 vs 67.6 years; P < .01) and were more likely to have end-stage renal disease (8.8% vs 0.8%; P = .01) and to present with anemia (10.5% vs 2.4%; P = .03). The TBAD anatomic features and management were similar in both groups. The rate of surgical intervention during hospitalization was 40% and 46% for the Black and White patients, respectively (P = .4). Black patients were more likely to be taking three or more hypertension agents (42.2% vs 16.4%; P = .005) and were less likely to be adherent to taking the prescribed agents (27.1% vs 6.7%; P < .001). Also, Black patients had fewer primary care physician visits before TBAD (P = .03) and more emergency department usage before TBAD (57.9% vs 26.9%; P < .001). Black patients had also had higher ADI scores (86.0 ± 14.6 vs 64.4 ± 21.3; P < .001). The median APACHE II score was the same for both Black and White patients (9 [interquartile range (IQR), 6-12] and 9 [IQR, 7-13], respectively; P = .7). The median hospital length of stay was identical for both groups (7 days; IQR, 5-13 days). The readmission rate was 24.5% for Black patients vs 15.5% for White patients (P = .16), with the 30-day mortality similar between the two groups (Black, 7.0%; White, 5.7%; P = .7). CONCLUSIONS: Black patients had presented at a younger age but with similar dissection morphology, rate of anatomic high-risk features, and APACHE II scores. The fewer primary care physician visits, greater emergency department usage, and higher ADI scores suggested lower health maintenance for the Black patients. White patients with TBAD were also highly deprived of health maintenance compared with the national percentile, indicating that TBAD is a disease that affects vulnerable populations, regardless of race.

Systematic review and meta-analysis of endovascular abdominal aortic repair in large diameter infrarenal necks.

OBJECTIVE: The aim of this study was to perform a meta-analysis of relevant published literature to investigate the impact of wide proximal aortic neck diameter on outcomes of endovascular aneurysm repair (EVAR) for the repair of abdominal aortic aneurysm (AAA). METHODS: A systematic literature review was performed to examine the rate of clinical safety and effectiveness end points associated with wide proximal aortic neck diameter after EVAR for the treatment of AAA. A literature search was performed on August 9, 2019, using PubMed as the primary database and Cochrane as the secondary database. In all, there were 11 full articles included in the quantitative and qualitative analyses. RESULTS: There was a total of 7448 patients who were treated for AAA with EVAR. Of these, 26.9% of patients were defined as having wide necks by the individual publications. The definition of wide neck varied in the literature and ranged from 25 mm or greater to 30 mm or greater. The percentage of male patients was 89.1% in the included articles. The mean or median age range was 72.7 to 76.5 years, which was similar for the wide and normal neck groups. Follow-up ranged from 2 to 5 years. Type I and Ia endoleaks occurred at a higher rate in the wide neck group compared with the normal neck group (11.3% vs 3.1%; P < .001). There was no difference in the rate of type Ib endoleaks between the wide and normal neck groups. The weighted averages of composite major adverse events and aneurysm-related mortality were all greater in the wide neck group (33.5% and 15.3%, respectively) compared with the normal neck group (21.2% and 3.9%, respectively) (P = .004). CONCLUSIONS: The rates of type Ia endoleaks, reinterventions, and migrations were all significantly higher in the wide neck patient group compared with patients with normal aortic neck size through follow-up. The results of this literature review showed that, although EVAR for the treatment of AAA in patients with a wide aortic neck is feasible, there is a higher risk for complications, interventions, and mortality. In particular, type Ia endoleak is a risk, which could be mitigated by using proximal seal strategies.

Retinal artery occlusion does not portend an increased risk of stroke.

OBJECTIVE: The aim of this study was to determine the subsequent risk of stroke after a diagnosis of retinal artery occlusion (RAO). We hypothesized that the risk would be low and comparable to that of the general population. RAO is relatively rare and often incorrectly diagnosed. We believe our institution is in a unique position to investigate this relationship with both a high-volume eye center and vascular laboratory. METHODS: This was a retrospective, single-institution review of 221 patients diagnosed with RAO from 2004 to 2018, confirmed with fluorescein angiography. Demographics, comorbidities, imaging of the carotid arteries, and prospective events, such as stroke, myocardial infarction (MI), and death, were recorded. Time to first stroke, first MI, and death was estimated using Kaplan-Meier estimation separately and as a composite end point. RESULTS: There were 221 patients identified with a confirmed diagnosis of RAO. The mean age in the cohort was 66.1 years; 53% of patients were male, and 29% were diabetic. Median length of follow-up was 2.2 years. Five patients (2.3%) had a documented stroke; four of the five strokes occurred at the time of RAO, with one that was contralateral occurring at 1.2 years. There were eight MIs (3.6%) in the cohort, two of which resulted in death. Twenty-two patients (10%) experienced a stroke, MI, or death. There were 141 (63.8%) patients who had carotid imaging performed, of whom 20 (14.2%) were found to have >50% stenosis. CONCLUSIONS: The rate of stroke in patients with confirmed RAO was 2.3%; however, excluding concurrent ischemic events, the risk was <1%. The incidence of carotid artery stenosis >50% was 14.2%. The authors conclude that the risk of stroke after confirmed RAO is lower than previously reported and comparable to prior population-based studies of all at-risk adults.