Predictors of Long-term Aortic Growth and Disease Progression in Patients With Aortic Dissection, Intramural Hematoma, and Penetrating Aortic Ulcer

Abstract

The objective was to investigate predictors of long-term aortic diameter change and disease progression in a population cohort of patients with newly diagnosed aortic dissection (AD), intramural hematoma (IMH), or penetrating aortic ulcer (PAU). We used the Rochester Epidemiology Project record linkage system to identify all Olmsted County, Minnesota, residents diagnosed with AD, IMH, and PAU (1995-2015). Only patients with at least two available imaging studies were included. The primary outcome was aortic diameter change. Secondary outcomes were freedom from disease progression (defined by any related intervention, aortic aneurysm, new aortic syndrome, rupture, or death) and disease resolution (defined by complete spontaneous radiologic disappearance). Linear regression models were used to assess aortic growth rate; Cox proportional hazards models were used to identify predictors of disease progression or resolution. Of 133 total incident cases, 46 ADs, 12 IMHs, and 28 PAUs with sufficient imaging data were included in the analysis. Overall median follow-up was 8.1 years. Aortic diameter increase was seen in 40 ADs (87%; median 1.0 mm/y), 5 IMHs (42%; median, 0.2 mm/y), and 14 PAUs (50%; median, 0.4 mm/y) during follow-up. A symptomatic presentation (P = .045), connective tissue disorders (P = .005), and initial maximum aortic diameter >42 mm (P = .013) were significant predictors of aortic growth rate for AD. Female sex (P = .013) and initial PAU depth >9 mm (P = .047) were significantly associated with growth rate in PAUs. No predictors of aortic growth rate were identified for IMHs. At 10 years, freedom from disease progression was 22% (95% confidence interval [CI], 12-41) for ADs, 44% (95% CI, 22-92) for IMHs, and 46% (95% CI, 27-78) for PAUs; most events occurred within 5 years (n = 34 [73%]), 9 (17%) after 5 to 10 years, and 5 (9%) >10 years from the diagnosis. Initial maximum aortic diameter was a significant predictor of IMH progression (hazard ratio, 1.4; 95% CI, 1.0-1.9; P = .037); no progression predictors were identified for ADs and PAUs. No AD spontaneously resolved; mortality-free resolution rate at 10 years was 22% (95% CI, 0-45) for IMHs and 11% (95% CI, 0-23) for PAUs. There were no predictors of disease resolution. Aortic growth is observed in most patients with AD, IMH, or PAU. Disease progression is frequent and may occur also after 10 years from the initial diagnosis, whereas a spontaneous resolution is uncommon. Follow-up imaging, particularly early after aortic events, is important in these patients. High-risk predictors of aortic growth rate and disease progression should be used to additionally tailor appropriate aortic follow-up.