The Long-term Fate of Aortic Branches in Patients With Aortic Dissection

Abstract

ABSTRACT Objective Late morbidity and mortality related to aortic branches in patients with aortic dissection (AD) are not well described. We aimed to investigate the fate of aortic branches in a population cohort of patients with newly diagnosed AD. Methods We used the Rochester Epidemiology Project record linkage system to identify all Olmsted County, MN, residents diagnosed with AD from 1995 to 2015. Only patients with >30 days of available follow-up imaging were included in the analysis. The primary outcome was freedom from any branch-related event (any intervention, aneurysm, malperfusion, rupture, or death occurring after the acute phase >14 days). Secondary outcome was the diameter change of the aortic branches. Univariate and multivariable Cox proportional hazards models were used to identify predictors of branch-related events; univariate and multivariate linear regression models were used to assess aortic branches growth rate. Results Of 77 total incident AD cases, 58 patients who survived with imaging follow-up were included, 28 (48%) with type A and 30 (52%) with type B AD. The presentation was acute in 39 (67%) cases; 6 (10%) had branch malperfusion. Of 177 aortic branches involved by the AD, 81 (46%) arose from the true lumen, 33 (19%) from the false lumen, 63 (36%) from both. After the acute phase, freedom from any branch-related event at 15 years was 48% (95%CI 32-70). Thirty-one branch-related events occurred in 19 patients over 15 years: 12 interventions (76% freedom, 95%CI 63-92), 10 aneurysms (67% freedom, 95%CI 50-90), 8 malperfusions (76% freedom, 95%CI 61-94) and 1 rupture (94% freedom, 95%CI 84-100). There were no branch-related deaths. Type B AD (HR 3.5, 95%CI 1.1-10.8; P=.033), patency of the aortic false lumen (HR 6.8, 95% CI 1.1-42.2; P=.038) and malperfusion syndrome at presentation (HR 6.0, 95% CI 1.3-28.6; P=.023) were predictors of late aortic branches-related events. Overall growth rate of aortic branches was 1.3±3.0 mm/year. Patency of the aortic false lumen, initial branch diameter, and Marfan syndrome were significantly associated with diameter increase. Conclusions In patients with AD, aortic branch involvement was responsible for a significant long-term morbidity, without any related mortality. Type B AD, patency of the aortic false lumen, or malperfusion syndrome at presentation had a higher risk of branch events during the long-term follow-up. Dilatation of the aortic branches was observed in one third of cases during follow-up, in particular in case of a patent aortic false lumen or Marfan syndrome.