Readmission after early thoracic endovascular aortic repair versus medical management of acute type B aortic dissection.

BACKGROUND: The use of thoracic endovascular aortic repair (TEVAR) for the management of acute uncomplicated type B aortic dissection (TBAD) has increased. Although the results from early studies were promising, larger randomized trials evaluating TEVAR are lacking. It is also unclear where sufficient equipoise exists for such trials. In the present study, we evaluated the number of readmissions and unplanned operations after TEVAR vs those after medical management as the initial treatment of acute uncomplicated TBAD and the frequency of each treatment in this population. METHODS: We performed a multi-institutional retrospective review of patients with acute TBAD from 2015 to 2020 with the 1-year outcomes available, excluding patients with prior aortic intervention or chronic, iatrogenic or traumatic etiologies. The primary exposure was TEVAR vs medical management at the index admission. The patient demographics, clinical presentation, and imaging findings were analyzed using bivariate and multivariate logistic regression for the primary outcomes of unplanned readmission and/or operation after the initial admission. The secondary outcomes were mortality, myocardial infarction, stroke, renal failure requiring dialysis, retrograde type A dissection, and length of stay. We hypothesized that the readmissions would be higher with medical management. RESULTS: A total of 216 patients with TBAD (47 with complicated and 169 with uncomplicated) from two large academic centers were identified. Of the 169 patients with uncomplicated TBAD, 83 (49%) had been treated medically and 86 (51%) had undergone TEVAR at the initial admission. No differences were found in the demographics or high-risk imaging features at presentation. The medically managed patients had had higher rates of unplanned readmission (34% vs 9%; P = .0001) and operation (28% vs 8%; P = .0007) but shorter lengths of stay (6.3 vs 13.1 days; P < .0001). No differences were found in mortality, although the rate of myocardial infarction was higher in the medically managed group (10.8% vs 2.3%; P = .02). Although 28% of the medically managed patients had later required operation, they had had morbidity and mortality similar to those of patients who had undergone initial TEVAR. Initial medical management was associated with unplanned readmission (odds ratio, 8.3; P = .02) and the need for operation (odds ratio, 4.56; P = .006). No differences were found in the outcomes according to the involved aortic zones. CONCLUSIONS: In the present study, medical management of acute uncomplicated TBAD was associated with higher rates of readmission and the need for unplanned operation compared with TEVAR. However, no differences were found in the 1-year mortality for the patients for whom medical management had failed. Because one half of the patients had undergone medical management and one half had undergone early TEVAR, this finding suggests clinical equipoise for the treatment of acute uncomplicated TBAD. Therefore, a larger randomized trial appears warranted to determine whether a clear benefit exists for early TEVAR.

Left subclavian artery revascularization is associated with less neurologic injury after endovascular repair of acute type B aortic dissection.

OBJECTIVE: The aim of this study was to analyze patients with acute type B aortic dissection (aTBAD) requiring thoracic endovascular aortic repair (TEVAR) with left subclavian artery (LSA) coverage to determine whether LSA revascularization decreased the risk of neurologic complications. METHODS: The national Vascular Quality Initiative TEVAR module was queried for all procedures performed between 2014 and 2021. Patients presenting with aortic aneurysms or aortic ruptures were excluded from the analysis. Patients were divided into two groups according to whether their LSA was revascularized (prior to or during TEVAR) or not. Univariate followed by multivariate analysis was used to account for possible confounders and evaluate the association of LSA revascularization with the primary outcome of neurologic injury (stroke or spinal cord ischemia). RESULTS: Among patients who had TEVAR for aTBAD, 501 patients had the LSA covered. The LSA was revascularized prior to or concomitant with TEVAR in 28% of these patients (n = 139). Average age was 57 years, and 73% (n = 366) were male. Neurologic injury developed in 88 patients (18%). On univariate analysis, patients who had their LSA revascularized were significantly less likely to develop neurologic injury (10% vs 20%; P < .01). This association persisted after accounting for potential confounders (odds ratio, 0.4; P = .02). No significant difference was seen when comparing 30-day or 1-year mortality between patients who had LSA revascularization and those who did not. Follow-up averaged 1.9 years (range, 0-8.1 years). Long-term survival did not differ between the two groups on Kaplan-Meier analysis. CONCLUSIONS: In this study of patients with aTBAD who underwent LSA coverage during TEVAR, the addition of a LSA revascularization procedure was associated with a significantly lower incidence of neurological injury including spinal cord ischemia and/or stroke.

A Comparative Study of Clinical and Aortic Morphological Characteristics between Bovine Aortic Arch and Normal Aortic Arch in Patients with Acute Type B Aortic Dissection.

INTRODUCTION: The purpose of this study was to analyze the difference in clinical and aortic morphological features between the bovine aortic arch and normal aortic arch in patients with acute type B aortic dissection (aTBAD). METHODS: A total of 133 patients diagnosed with aTBAD were retrospectively collected. Based on aortic arch morphology, they were divided into the bovine aortic arch group (n = 20) and the normal aortic arch group (n = 113). Aortic morphological features were assessed on computed tomographic angiography. Clinical and aortic morphological features were then compared between the bovine aortic arch and normal aortic arch groups. RESULTS: Patients in the bovine aortic arch group were significantly younger and with higher weight and BMI than the normal aortic arch group (p < 0.001, p = 0.045, and p = 0.016, respectively). The total aortic length in the bovine aortic arch group was significantly shorter than that in the normal aortic arch group (p = 0.039). The tortuosity of descending thoracic aorta, the tortuosity of descending aorta, and the angulation of aortic arch were significantly lower in the bovine aortic arch group (p = 0.004, p = 0.015, and p = 0.023, respectively). The width of descending aorta, the height of aorta arch, and the angle of ascending aorta were significantly smaller in the bovine aortic arch group (p = 0.045, p = 0.044, and p = 0.042, respectively). CONCLUSION: When the aTBAD occurred, patients with bovine aortic arch were prone to be younger and with higher BMI than those with normal aortic arch. The aortic curvature and the total aortic length were lower in patients with bovine aortic arch.

A prediction model to predict in-hospital mortality in patients with acute type B aortic dissection.

BACKGROUND: Acute type B aortic dissection (ABAD) is a life-threatening cardiovascular disease. A practicable and effective prediction model to predict and evaluate the risk of in-hospital death for ABAD is required. The present study aimed to construct a prediction model to predict the risk of in-hospital death in ABAD patients. METHODS: A total of 715 patients with ABAD were recruited in the first affiliated hospital of Xinjiang medical university from April 2012 to May 2021. The information on the demographic and clinical characteristics of all subjects was collected. The logistic regression analysis, receiver operating characteristic (ROC) curve analysis, and nomogram were applied to screen the appropriate predictors and to establish a prediction model for the risk of in-hospital mortality in ABAD. The receiver operator characteristic curve and calibration plot were applied to validate the performance of the prediction model. RESULTS: Of 53 (7.41%) subjects occurred in-hospital death in 715 ABAD patients. The variables including diastolic blood pressure (DBP), platelets, heart rate, neutrophil-lymphocyte ratio, D-dimer, C-reactive protein (CRP), white blood cell (WBC), hemoglobin, lactate dehydrogenase (LDH), procalcitonin, and left ventricular ejection fraction (LVEF) were shown a significant difference between the in-hospital death group and the in-hospital survival group (all P < 0.05). Furthermore, all these factors which existed differences, except CRP, were associated with in-hospital deaths in ABAD patients (all P < 0.05). Then, parameters containing LVEF, WBC, hemoglobin, LDH, and procalcitonin were identified as independent risk factors for in-hospital deaths in ABAD patients by adjusting compound variables (all P < 0.05). In addition, these independent factors were qualified as predictors to build a prediction model (AUC > 0.5, P < 0.05). The prediction model was shown a favorable discriminative ability (C index = 0.745) and demonstrated good consistency. CONCLUSIONS: The novel prediction model combined with WBC, hemoglobin, LDH, procalcitonin, and LVEF, was a practicable and valuable tool to predict in-hospital deaths in ABAD patients.

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.

Venovenous extracorporeal membrane oxygenation for acute respiratory distress syndrome due to an acute type B aortic dissection: a case report.

Acute type B aortic dissection is sometimes complicated by acute respiratory failure requiring mechanical ventilation. Herein, we describe our experience in a rare acute type B aortic dissection-associated respiratory failure case culminating in acute respiratory distress syndrome. The patient was a 45-year-old man admitted with a complaint of sudden chest pain radiating to his back. On computed tomography, an acute type B aortic dissection was diagnosed. He had no dyspnea on admission, but his respiratory function subsequently deteriorated, and severe acute respiratory distress syndrome was diagnosed on Day 4. Venovenous extracorporeal membrane oxygenation with anticoagulation plus continuous renal replacement therapy for oliguria improved the oxygenation, and the patient was weaned from the extracorporeal membrane oxygenation on Day 8. This patient fully recovered without worsening the aortic dissection, using venovenous extracorporeal membrane oxygenation with anticoagulation plus a continuous renal replacement therapy.

Prognostic dynamic nomogram integrated with metabolic acidosis for in-hospital mortality and organ malperfusion in acute type B aortic dissection patients undergoing thoracic endovascular aortic repair.

BACKGROUND: Organ malperfusion is a lethal complication in acute type B aortic dissection (ATBAD). The aim of present study is to develop a nomogram integrated with metabolic acidosis to predict in-hospital mortality and organ malperfusion in patients with ATBAD undergoing thoracic endovascular aortic repair (TEVAR). METHODS: The nomogram was derived from a retrospectively study of 286 ATBAD patients who underwent TEVAR from 2010 to 2017 at a single medical center. Model performance was evaluated from discrimination and calibration capacities, as well as clinical effectiveness. The results were validated using a prospective study on 77 patients from 2018 to 2019 at the same center. RESULTS: In the multivariate analysis of the derivation cohort, the independent predictors of in-hospital mortality and organ malperfusion identified were base excess, maximum aortic diameter ≥ 5.5 cm, renal dysfunction, D-dimer level ≥ 5.44 µg/mL and albumin amount ≤ 30 g/L. The penalized model was internally validated by bootstrapping and showed excellent discriminatory (bias-corrected c-statistic, 0.85) and calibration capacities (Hosmer-Lemeshow P value, 0.471; Brier Score, 0.072; Calibration intercept, - 0.02; Slope, 0.98). After being applied to the external validation cohort, the model yielded a c-statistic of 0.86 and Brier Score of 0.097. The model had high negative predictive values (0.93-0.94) and moderate positive predictive values (0.60-0.71) for in-hospital mortality and organ malperfusion in both cohorts. CONCLUSIONS: A predictive nomogram combined with base excess has been established that can be used to identify high risk ATBAD patients of developing in-hospital mortality or organ malperfusion when undergoing TEVAR.

Impact of high blood pressure variability on the occurrence of acute type B aortic dissection.

BACKGROUND: Acute type B aortic dissection is a life-threatening medical emergency, and hypertension is believed to be an important predictor of aortic dissection; the impact of blood pressure variability on the onset and development of aortic dissection has attracted increasing attention. METHODS: A total of 120 acute type B aortic dissection patients and 57 hypertensive patients without aortic dissection were consecutively enrolled and retrospectively reviewed between January 2013 and November 2015. There were 60 acute type B aortic dissection patients in both high and low blood pressure variability groups. RESULTS: Blood pressure variability showed higher diagnostic value than hypertension in aortic dissection, and the best threshold of blood pressure variability is 5.71 mmHg. By performing multivariable logistic regression, we found that the history of hypertension was likely to be a risk factor of blood pressure variability (95% CI: 1.155-6.422, P = 0.022). Nine patients from high blood pressure variability group and two from low blood pressure variability group (χ2 = 4.90, P = 0.027) received emergency surgery within 24 hours after admission. The presence of multiple tears (>2, 55.0% vs. 45.0%, P = 0.001), configuration of the false lumen (spiral false lumen) (50.0% vs. 21.7%, P = 0.001), the diameter of the false lumen (49.6 ± 15.0 mm vs. 37.6 ± 10.8 mm, P < 0.001), the false/true lumen ratio (1.53 ± 1.02 vs. 0.929 ± 0.733, P < 0.001), and the number of visceral arteries involved (1.75 ± 0.942 vs. 0.800 ± 0.927, P < 0.001) showed significant differences between high and low blood pressure variability groups. Nine (30%) patients from the high blood pressure variability group showed a maximum diameter of false lumen over 60 mm, while none was found in the low blood pressure variability group. CONCLUSIONS: High blood pressure variability, the presence of multiple tears (>2), the configuration of false lumen, the diameter of the false lumen, false/true lumen ratio, and the number of visceral arteries involved were independent risk factors for acute type B aortic dissection.

The role of ascending aortic size in outcomes of patients with uncomplicated acute type B aortic dissection.

OBJECTIVE: Recent studies demonstrate that uncomplicated acute type B aortic dissection (uATBAD) patients with enlarged descending thoracic aortic diameters are at high risk for development of complications. This study aimed to determine the association of maximum ascending aortic diameter and area and outcomes in patients with uATBAD. METHODS: All patients admitted with uATBAD from June 2000 to January 2015 were reviewed, and those with available imaging were included. All measurements were obtained by a specialized cardiovascular radiologist, including the maximum ascending aortic diameter and area. Outcomes, including the need for intervention and mortality, were tracked over time. Data were analyzed by stratified Kaplan-Meier and multiple Cox regression analyses using SAS 9.4 software (SAS Institute, Cary, NC). RESULTS: During the study period, 298 patients with uATBAD were admitted, with 238 having available computed tomography and 131 having computed tomography angiography imaging and adequate follow-up available for analysis. The cohort had an average age of 60.96 ± 13.4 years (60% male, 53% white). Ascending aortic area >12.1 cm2 and ascending aortic diameter >40.8 mm were associated with subsequent arch and proximal progression necessitating open ascending aortic repair (P < .027 and P < .033, respectively). Ascending diameter >40.8 mm predicted lower intervention-free survival (P = .01). However, it failed to predict overall survival (P = .12). Ascending aortic area >12.1 cm2 predicted lower intervention-free survival (P = .005). However, this was not predictive of mortality (P = .08). Maximum aortic diameter along the length of the aorta >44 mm persisted as a risk factor for mortality (P < .001). Neither maximum ascending aortic diameter >40.8 mm (hazard ratio [HR], 1.09; 95% confidence interval [CI], 0.42-2.83; P = .85) nor area >12.1 cm2 (HR, 0.992; 95% CI, 0.38-2.61; P = .99) significantly predicted mortality when controlling for maximum aortic diameter along the length of the aorta >44 mm (HR, 7.34; 95% CI, 2.3-23.41; P < .001), diabetes mellitus (HR, 6.4; 95% CI, 2.17-18.93; P < .001), age (HR, 1.06/y; 95% CI, 1.03-1.10; P < .001), history of stroke (HR, 5.03; 95% CI, 1.52-16.63; P = .008), and syncope on admission (HR, 21.11; 95% CI, 2.3-193.84; P = .007). Ascending aortic diameter >40.8 mm (HR, 2.01; 95% CI, 1.03-3.95; P = .04) and maximum ascending aortic area >12.1 cm2 (HR, 1.988; 95% CI, 1.02-3.87; P = .04) on admission persisted as predictors of decreased intervention-free survival after controlling for maximum aortic diameter along the length of the aorta >44 mm (HR, 3.142; 95% CI, 1.47-6.83; P < .004), syncope on admission (HR, 26.3; 95% CI, 2.81-246; P < .004), and pleural effusion on admission (HR, 3.02; 95% CI, 1.58-5.77; P < .001). CONCLUSIONS: uATBAD patients with ascending aortic area >12.1 cm2 or maximum ascending aortic diameter >40.8 mm are at high risk for development of subsequent arch and proximal progression and may require closer follow-up or earlier intervention. Ascending aortic size (diameter and area) is predictive of decreased intervention-free survival in patients with uATBAD.

Influence of distal extension of false lumen on adverse aortic events after TEVAR in patients with acute type B aortic dissection.

OBJECTIVE: To investigate the clinical outcomes influenced by distal extension of false lumen in acute type B aortic dissection (TBAD) patients following thoracic endovascular aortic repair (TEVAR). METHODS: From April 2002 to January 2013, 264 TBAD patients treated with TEVAR were retrospectively enrolled. The IIIa group exhibited a distal false lumen above the diaphragm (n = 70), and the IIIb group exhibited a distal false lumen under the diaphragm (n = 194). The morphological characteristics and adverse events (30-day and >30 days) were recorded and evaluated. RESULTS: There were no significant differences between the two groups regarding the demographics, comorbidity profiles, or initial feature of computed tomography angiography. The incidence of true lumen compression and branch involvement were significantly increased in the IIIb group compared with the IIIa group (8.6% vs. 25.3%, respectively; 15.7% vs. 36.1%, respectively, both P < 0.05). The 30-day mortality rate was 1.0% (2/194) in the IIIb group, whereas the IIIa group was zero. The incidence of early adverse events, the 5-year cumulative freedom from adverse events, and the 5-year cumulative freedom from all-cause mortality rate were not significantly different between the IIIa and IIIb groups (2.9% vs. 6.7%, 81.4%, and 80.4%, and 95.7% vs. 93.8%, respectively, all P > 0.05). Log-rank tests also indicated there was no significant difference. CONCLUSIONS: There was no significant difference between the IIIa and IIIb groups in the 5-year morality and adverse aortic events following TEVAR. The distal extension of false lumen prior to TEVAR does not influence the long-term morality and adverse aortic events in acute TBAD.

Early and Long-term Outcome after Open Surgical Suprarenal Aortic Fenestration in Patients with Complicated Acute Type B Aortic Dissection.

OBJECTIVES: The purpose of this retrospective cohort study was to determine the early and long-term mortality and morbidity as well as to reveal risk factors influencing the long-term prognosis in patients with complicated acute type B aortic dissection (CABAD) undergoing open surgical suprarenal aortic fenestration (OSSAF). METHODS: Fifty-two patients with CABAD, defined as (impending) rupture, acute enlargement of the false lumen, malperfusion, and/or unrelenting back pain or uncontrollable hypertension despite maximum medical therapy were treated with by surgical repair between 2002 and 2008. Ten patients with (impending) rupture had aortic graft replacement, while 42 (33 men, mean age 55 ± 11 years) had OSSAF. Follow up visits were scheduled at 1, 3-6 and 12 months after the surgery and annually thereafter. Clinical examination and computed tomography angiography findings were investigated at baseline and at subsequent visits. RESULTS: The indications for OSSAF were acute enlargement of the false lumen in four (10%), malperfusion in 17 (40%) (11 lower extremity [26%], 6 visceral [14%]), and unrelenting back pain or uncontrollable hypertension in 21 cases (50%). The 30 day mortality was 21.4% (2 multiple organ failure, 2 heart failure, 3 pneumonia, 1 intestinal necrosis, 1 major hemorrhage). The mean follow up was 84 ± 40 months. The 5 year survival was 70.6%. Eight patients (19%) died during the follow up period (6 aortic ruptures, 2 myocardial infarctions). None of the patients became paraplegic after the surgery. Further surgery or stenting was indicated in nine cases (21%). CONCLUSIONS: OSSAF has been performed with an acceptable early mortality and low paraplegia rate, but late mortality is frequently related to aortic rupture. Stentgraft coverage of the primary entry tear decreases late aortic related deaths, but suprarenal fenestration remains an option for cases not suitable for endovascular techniques.

Endovascular management of rupture in acute type B aortic dissections.

OBJECTIVE: Reports of thoracic endovascular aortic repair (TEVAR) for complicated acute type B aortic dissection (ABAD) bring together a large range of clinical presentations. With a 30 day mortality of 50% when managed with open surgery, rupture is the most devastating complication of ABAD. This study investigated the outcome of TEVAR for ABAD complicated by rupture (r-ABAD) to assess the results of this particularly critical subgroup. METHODS: A review of consecutive TEVAR for r-ABAD in two tertiary referral centers was performed using a prospectively maintained database. RESULTS: Between 2000 and 2013, 24 patients (mean age 71 years; 14 males) underwent TEVAR for r-ABAD. Sixteen (67%) were in shock (Systolic blood pressure <80 mmHg) before surgery. Seven patients had coverage of the left subclavian artery, of whom four had partial arch debranching procedures via cervical access concomitant with TEVAR. Median length of aortic coverage was 150 mm, median proximal oversizing was 13.3% (range 6.2-33.3%). Technical success was achieved in 100%. There were four in hospital deaths (16%). Two patients (8%) had paraplegia, but neither stroke nor renal insufficiency requiring dialysis occurred. During a mean follow up of 28 months, there was one aortic dissection related death and eight patients (40% of the surviving patients) required re-intervention. All re-interventions were managed endovascularly. At last follow up CT scan, eight patients (40%) had complete remodeling of the aortic wall. CONCLUSION: With 16% in hospital mortality and 8% early major complications, this study confirms the feasibility of TEVAR for r-ABAD with a lower peri-operative morbidity and mortality rate compared with open surgery. Given the high rate of re-intervention, close follow up is required in surviving patients.

Acute type B aortic dissection with multiple cholesterol embolism: an autopsy case report.

Background: Most cases of cholesterol embolism are known to be triggered by cardiac catheterization, cardiovascular surgery, anticoagulation, or fibrinolytic therapy; however, spontaneous cases after aortic dissection are rare. In this report, we describe a case of cholesterol embolism after type B aortic dissection, which rapidly developed into multiple organ failure and death. Case summary: A 65-year-old man with untreated hypertension was admitted to our hospital with sudden back pain and diagnosed with type B aortic dissection. The patient experienced a rapid progression of inflammation and developed respiratory and renal failure, despite computed tomography showing no obvious progression of dissection. We attributed them to a cytokine storm and acute respiratory distress syndrome, but steroid pulse therapy did not alleviate the symptoms. Finally, the patient died on Day 6 after admission, and an autopsy was performed, which revealed cholesterol crystal occlusions in the kidney, spleen, and the left lower leg. The lumen in the aorta is filled with atheroma and thrombus, and we suspect that aortic dissection triggered failure of the aortic plaques and released cholesterol crystals to distal arteries that led to cholesterol embolism. Discussion: We experienced a patient with a type B aortic dissection that led to cholesterol embolism and rapid progression of respiratory and renal failure, resulting in death. The aortic dissection combined with cholesterol embolism was considered to trigger the subsequent severe inflammation, leading to rapid respiratory and renal failure. Our case points to the possibility that cholesterol embolism can extensively escalate inflammation after aortic dissection.

Endovascular treatment of complicated versus uncomplicated acute type B aortic dissection.

OBJECTIVE: The study objective was to analyze the outcomes of thoracic endovascular aortic repair performed for complicated and uncomplicated acute type B aortic dissections. METHODS: Patients from WL Gore's Global Registry for Endovascular Aortic Treatment who underwent thoracic endovascular aortic repair for acute type B aortic dissections were included, and data were retrospectively analyzed. RESULTS: Of 5014 patients enrolled in the Global Registry for Endovascular Aortic Treatment, 172 underwent thoracic endovascular aortic repair for acute type B aortic dissections. Of these repairs, 102 were for complicated acute type B aortic dissections and 70 were for uncomplicated acute type B aortic dissections. There were 46 (45.1%) procedures related to aortic branch vessels versus 15 (21.4%) in complicated type B aortic dissections and uncomplicated type B aortic dissections (P = .002). The mean length of stay was 14.3 ± 10.6 days (median, 11; range, 2-75) versus 9.8 ± 7.9 days (median, 8; range, 0-42) in those with complicated type B aortic dissections versus those with uncomplicated acute type B aortic dissections (P < .001). Thirty-day mortality was not different between groups (complicated type B aortic dissections 2.9% vs uncomplicated acute type B aortic dissections 1.4%, P = .647), as well as aortic complications (8.8% vs 5.7%, P = .449). Aortic event-free survival was 62.9% ± 37.1% versus 70.6% ± 29.3% at 3 years (P = .696). CONCLUSIONS: In the Global Registry for Endovascular Aortic Treatment, thoracic endovascular aortic repair results for complicated type B aortic dissections versus uncomplicated acute type B aortic dissections showed that 30-day mortality and perioperative complications were equally low for both. The midterm outcome was positive. These data confirm that thoracic endovascular aortic repair as the first-line strategy for treating complicated type B dissections is associated with a low risk of complications. Further studies with longer follow-up are necessary to define the role of thoracic endovascular aortic repair in uncomplicated acute type B dissections compared with medical therapy. However, in the absence of level A evidence from randomized trials, results of the uncomplicated acute type B aortic dissection patient cohort treated with thoracic endovascular aortic repair from registries are important to understand the related risk and benefit.

Comparison of population characteristics and clinical outcomes of patients with type B aortic dissection or aortic intramural hematoma underwent thoracic endovascular aortic repair: a propensity score-matched analysis.

BACKGROUNDS: Survival and aortic-related adverse events after thoracic endovascular aortic repair (TEVAR) for aortic intramural hematoma (IMH) and aortic dissection (AD) are controversial. We aimed to assess the preoperative characteristics and to evaluate TEVAR outcomes of acute type B IMH and AD. METHODS: Between June 2002 and May 2021, 83 patients with acute type B IMH and 755 patients with acute type B AD underwent TEVAR at the General Hospital of Northern Theater Command. We retrospectively analyzed data from these patients, including clinical characteristics and follow-up outcomes. RESULTS: The patients with IMH were significantly older than the ones with AD (P < 0.001). Diabetes mellitus (P = 0.035) and ischemic cerebrovascular disease (P = 0.017) were more common in the IMH group than in the AD group. The results demonstrated a less long-term aortic-related death-free survival rate in the IMH group than the AD group for all the patients (P = 0.014) and the matched patients (P = 0.027). It also presents a lower long-term overall survival rate (P = 0.047) and aortic-related event-free rate (P = 0.048) in the IMH group than in the matched patients. CONCLUSIONS: Compared with AD patients, patients with IMH who underwent TEVAR had a worse long-term outcome of aortic-related survival in all and matched patients.

Short-term follow-up of proximal aorta remodeling after zone 2 thoracic endovascular aortic repair for acute type B aortic dissection.

BACKGROUND: To evaluate the early remodeling of the proximal aorta in patients with acute type B aortic dissection (ATBAD) after zone 2 thoracic endovascular aortic repair (TEVAR). METHODS: From January 2016 to May 2022, 53 ATBAD patients underwent zone 2 TEVAR were divided into two groups, the Castor single-branched stent-graft (CSS) group (n = 26) and the common stent-graft group (n = 27). Three-dimensional imaging created by computed tomography angiography was used to measure different parameters of the aorta, such as angulation, cross-sectional area (CSA), length and tortuosity. Early remodeling of the proximal aorta was evaluated by comparing geometric parameters of the proximal aorta before and 3 months after surgery. RESULTS: In terms of angle, the postoperative angle of aortic arch to ascending aorta, descending aorta increased in all patients compared with that before surgery (all P < 0.05), while the angle of aortic arch to left subclavian artery increased after surgery only in the CSS group (P < 0.001); As for CSA, the CSA of distal aortic arch and true lumen increased (all P < 0.05), while the CSA of false lumen decreased in both groups after operation (all P < 0.05); Only in CSS group, the CSA of the ascending aorta, proximal aortic arch and total descending thoracic aorta decreased after surgery (all P < 0.05); In terms of length, the aortic arch prolonged after operation in both groups (P = 0.018 and P = 0.004, respectively). In addition, the ascending aorta tortuosity decreased in the CSS group after surgery (P = 0.011). There was no significant difference in the alterations of other aortic parameters after operation (P > 0.05). CONCLUSIONS: The CSS implantation provided a more relatively safe and effective treatment for acute type B aortic dissection patients with unfavorable proximal landing zone. It can promote the earlier remodeling of the proximal aorta compared with the common stent-graft implantation after zone 2 TEVAR.

Intensive care unit management of uncomplicated type B aortic dissection in relation to treatment period: a retrospective observational study.

BACKGRUOUND: Medical therapy is the standard treatment for uncomplicated acute type B aortic dissection (ATBAD), but there is little evidence of the need for intensive care unit (ICU) management. Therefore, we aimed to investigate the effects of ICU treatment on uncomplicated ATBAD. METHODS: We retrospectively studied patients with uncomplicated ATBAD who were medically treated between January 2010 and July 2020. Patients were divided into long-term ICU stay (LIS) and short-term ICU stay (SIS) groups, according to a 48-hour cutoff of ICU stay duration. The incidence of pneumonia and delirium, rate of aortic events, hospital mortality, and survival rate were compared. RESULTS: Fifty-five patients were treated for uncomplicated ATBAD (n=26 for LIS and n=29 for SIS). The incidence of pneumonia (7.7% vs. 3.6%) and delirium (34.6% vs. 14.3%) was higher in the LIS group than in the SIS group, but the differences were not statistically significant. The survival rates at 1, 3, and 5 years were not different between the two groups (LIS: 96.2%, 88.0%, and 54.2% vs. SIS: 96.4%, 92.2%, and 75.5%, respectively; p=0.102). Multivariate Cox regression analysis for aortic events showed that using a calcium channel blocker lowered the risk of aortic events. CONCLUSION: Long-term ICU treatment is unlikely to be necessary for the treatment of uncomplicated ATBAD. Active use of antihypertensive agents, such as calcium channel blockers, may be needed during the follow-up period.

Aortic arch type, a novel morphological indicator and the risk for acute type B aortic dissection.

OBJECTIVES: Aortic arch type is a readily recognizable and obtainable morphological feature of the aorta that does not require complex measurements. The goal of this study was to evaluate whether aortic arch type is a comparable and alternative morphological parameter for predicting acute type B aortic dissection (aTBAD) by comparing the prognostic value of the aortic arch type with that of other morphological parameters such as aortic length, angulation and tortuosity index. METHODS: The patients with aTBAD (n = 216) were matched 1:1 with a control group (n = 263) by propensity score matching. The morphological data of the ascending aorta and the aortic arch, which included diameter, length, angulation and tortuosity index, were collected on a three-dimensional aortic model using 3mensio Vascular software. The aortic arch type was identified by the vertical distance from the origin of the brachiocephalic trunk to the top of the arch. The binary logistic regression models were analysed to determine the independent geometric variables related to the aTBAD. The nonparametric approach was performed to assess whether there were statistical differences between the area under the receiver operating characteristic curves (AUC) of the models. RESULTS: After propensity score matching, 151 matched pairs of patients were selected. The diameters at the sinotubular junction and the mid-ascending aorta, the ascending aorta length and the ascending aorta angulation in the aTBAD group were significantly greater than those of the controls. Compared with the control group, the diameters at the proximal aortic arch, mid-aortic arch and distal aortic arch, the angulation and the tortuosity index of the aortic arch were significantly greater in the aTBAD group. The proportion of the type III arch in the patients with aTBAD is higher than that of the type I arch and the type II arch (χ2 = 70.187; P < 0.001). Binary logistic regression analysis showed that the diameter at the mid-aortic arch, the ascending aorta length, the aortic arch angulation and the tortuosity index were independently related to the aTBAD with an AUC value of 0.887. Another binary logistic regression analysis indicated that the diameter at the mid-aortic arch and the aortic arch type were independent correlative variables associated with the aTBAD with an AUC of 0.874. No significant difference was observed in the prognostic value of receiver operating characteristic curves between the 2 models (P = 0.716). CONCLUSIONS: The type III arch, which has the characteristics of aortic elongation, incremental angulation and tortuosity index, is a comparable and alternative identifier for patients at high risk for aTBAD.

Spinal Cord Ischemia in the Setting of Acute Type B Aortic Dissection: Successful Rescue with Thoracic Endovascular Aortic Repair.

We report 2 cases of successful thoracic endovascular aortic repair (TEVAR) for acute type B aortic dissection (ABAD) complicated with spinal cord ischemia (SCI). Case 1. A 70-year-old gentleman found with an uncomplicated ABAD with false lumen occluded, developed SCI shortly after admission during the initial medical management. Cerebrospinal fluid drainage (CSFD) was initiated followed by emergent TEVAR. SCI improved, and the patient was discharged. Case 2. A 52-year-old gentleman developed uncomplicated ABAD with patent false lumen. 5 hours after admission, he developed SCI during the initial medical management. Emergent TEVAR was performed followed by CSFD, and the SCI improved before discharge. These cases prompted us to address prompt TEVAR for primary entry closure and true lumen dilatation with postoperative hypertensive management to relieve the dynamic obstruction of the segmental arteries responsible for the compromised spinal cord circulation in complicated ABAD.

Masquerade presentation of acute type B aortic dissection as isolated acute limb ischaemia treated with endovascular fenestration with angioplasty: A case report.

INTRODUCTION AND IMPORTANCE: Masquerade presentation of acute type B aortic dissections (TBAD) as acute limb ischaemia (ALI) is rare. Holistic clinical assessment, preferably with the help of scoring systems and timely computer tomographic angiogram (CTA), is needed for early diagnosis. Acute TBAD and its complications are increasingly treated with endovascular therapies. CASE PRESENTATION: A 21-year-old male with poorly controlled essential hypertension was admitted with prominent clinical features of ALI. No clinical pointers of a TBAD were present. Doppler ultrasound revealed an arterial occlusive pattern, and an urgent surgical embolectomy was performed. On failure to retrieve any thrombi, a CTA was performed, and diagnosis of TBAD complicated with ALI was made. The limb was revascularised with guidewire directed aortic fenestration with angioplasty. TBAD was managed conservatively. CLINICAL DISCUSSION: We report a case of acute TBAD presented as isolated ALI, which was initially diagnosed and treated as an ALI unrelated to aortic dissection. TBAD with typical or atypical clinical features presented with ALI as a malperfusion syndrome is not uncommon. However, masquerade presentations of TBAD as ALI are rare in the literature. Endovascular fenestration with or without stenting has fewer neurological complications and long-term mortality than thoracic endovascular aortic repair (TEVAR). Moreover, they become convenient in resource-poor settings without dedicated aortic centres. CONCLUSION: Masquerade presentation of TBAD should be recognised in the differential diagnosis of ALI. Timely CTA would prevent unnecessary interventions and help diagnose TBAD complicated with ALI. Despite their availability, outcomes will depend on proper patient selection for endovascular, surgical, and TEVAR options.