Uncomplicated Acute Type Research Articles

Background: Thoracic endovascular aortic repair (TEVAR) is the standard treatment for complicated type B aortic dissection, while randomized trials comparing TEVAR and optimal medical therapy for uncomplicated TBAD (uTBAD) are ongoing. Our previous study using a Japanese claims database reported long-term outcomes of uTBAD but did not include individuals aged ≥75 due to the bifurcated insurance system. Objective: To evaluate all-cause mortality associated with TEVAR versus non-TEVAR management in patients with acute uTBAD, including both elderly and non-elderly populations, using real-world data. Methods: We analyzed two national health claim databases, Cohort A (individuals aged ≥75) and Cohort B (self-employed individuals and their family members, all aged <75), from April 2014 to June 2024. Within each cohort, patients with acute uncomplicated type B aortic dissection (uTBAD) were identified using the same criteria. Patients receiving TEVAR during the subacute phase (15–90 days) were assigned to the TEVAR group; others to the non-TEVAR group. Propensity score matching (1:5) was performed separately in each cohort, adjusting for demographics, comorbidities, and medications. All-cause mortality was compared using Kaplan–Meier analysis. Results: After matching, 1,028 patients were included in Cohort A (TEVAR: 174; non-TEVAR: 854) and 730 in Cohort B (TEVAR: 122; non-TEVAR: 608). Median age in Cohort A was 80 (both groups), and in Cohort B was 66.5 (TEVAR) and 67 (non-TEVAR). Median follow-up was 29 vs. 27 months (IQR: 18–40 vs. 17–41) in Cohort A and 35 vs. 32 months (IQR: 19–51 vs. 17–49) in Cohort B for TEVAR and non-TEVAR groups, respectively. Kaplan–Meier analysis showed no significant difference in mortality between groups (log-rank p=0.2205 for A; p=0.2197 for B). Conclusion: In this nationwide real-world study, we observed no statistically significant differences in all-cause mortality between TEVAR and non-TEVAR management within either age cohort. These findings support the clinical equipoise underlying ongoing randomized controlled trials for uTBAD. Meanwhile, patient background and survival outcomes in the non-TEVAR groups within each cohort strongly suggest the influence of age-related confounding factors. Real-world data should be carefully interpreted when used to complement the generalizability of trial findings.

BackgroundThere is a lack of consensus on the benefit of early thoracic endovascular aortic repair (TEVAR) over medical management for uncomplicated acute type B aortic dissection (aTBAD). The aim of this study is to compare readmissions of TEVAR versus medical management as the initial treatment strategy for uncomplicated aTBAD using the Nationwide Readmissions Database (NRD).MethodsThe NRD was created under the Healthcare Cost and Utilization Project, comprising over half of the U.S. inpatient population. Patients admitted for uncomplicated aTBAD were queried from the NRD from 2016 to 2018. Risk of index admission mortality, spinal cord ischemia, stroke, and overall major complication; 90-day readmission and 90-day treatment failure, between TEVAR and medical management alone.ResultsA total of 12,645 patients with an uncomplicated aTBAD were identified (TEVAR 12% and medical management 88%). Overall major complications during index admission were higher in the medical management group (27% vs 40%, p < .0001). On multivariate analysis TEVAR was associated with lower mortality (OR: 0.47, p < .0001), but a significantly higher rate of spinal cord ischemia (OR: 2.49, p < .0001), with no difference in stroke (OR: 0.93, p = .73). 90-day readmission rates were high but were not significantly different between treatment types (22% vs 25%, OR: 0.88, p = .14). Similarly, TEVAR was not associated with a lower rate of 90-day treatment failure (OR: 0.61, p = .22). Four TEVAR (0.3%) and 40 medical management (0.5%) patients were readmitted for treatment failure due to retrograde type A dissection.ConclusionsTEVAR for uncomplicated aTBAD was not associated with a lower 90-day readmission rate. Similarly, TEVAR was not associated with a lower rate of 90-day treatment failure. These findings provide further evidence to the equipoise of treatment options and support the need for the randomized trials currently ongoing in the U.S. and Europe investigating outcomes of TEVAR versus medical management for the treatment of uncomplicated aTBAD.

ObjectivesTo compare the long-term outcomes of initial thoracic endovascular aortic repair (TEVAR) versus initial medical therapy (iMT) in patients with acute uncomplicated type B aortic dissection (uTBAD), using real-world evidence from a nationwide claims database in Japan. This study aligns with stage 4 of the Idea, Development, Exploration, Assessment, and Long-term Study (IDEAL) framework for surgical innovation.DesignA retrospective cohort study using propensity score matching (PSM) to balance baseline characteristics.SettingJapanese nationwide health insurance claims database, between 1 January 2015 and 31 December 2023.ParticipantsAmong 40 229 cases with tentative codes for aortic dissection (International Classification of Diseases-10: I71.0), 4995 met all eligibility criteria for acute uTBAD. Among these patients, 96 underwent TEVAR in the subacute phase (15–90 days post diagnosis), while 4899 were managed with iMT. After PSM, 96 TEVAR cases were matched to 480 iMT cases in a 1:5 ratio.Main outcome measuresThe primary outcomes were aorta-related events and all-cause mortality. The secondary outcome was the frequency of follow-up CT imaging every year.ResultsAfter PSM, the baseline characteristics of both groups were balanced. Median age was 56 years (IQR: 50–62 years) in both groups, and follow-up duration was similar (TEVAR: 31 months; iMT: 28 months, p=0.84).At 60 months, Kaplan-Meier estimates showed an aorta-related event rate of 21.9% (95% CI: 12.6% to 36.4%) for TEVAR and 19.9% (95% CI: 15.6% to 25.2%) for iMT (p=0.99).All-cause mortality was 4.4% (95% CI: 1.4% to 13.6%) for TEVAR and 6.6% (95% CI: 4.0% to 10.6%) for iMT (p=0.70). No significant differences were observed.ConclusionsWhile aorta-related events accumulated steadily in the crude iMT group, no survival benefit was observed for subacute TEVAR. These findings support ongoing randomized controlled trials and show the utility of claims-based analyses in IDEAL Stage 4.

ObjectiveFalse lumen expansion is a major factor that determines long-term survival of uncomplicated type B aortic dissection (TBAD). The objective of this study was to investigate whether structural wall stress distributions computed from patient-specific acute TBAD geometries can be used to predict aortic growth rates.MethodsThree-dimensional (3D) computed tomography angiography (CTA) of 9 patients with acute uncomplicated TBAD were obtained at initial hospital admission and at their most recent follow-up visits. Patient-specific structural wall stress distributions were computed from the initial baseline CTA using a forward penalty method. Spatially varying blood pressure distributions, derived from computational fluid dynamics (CFD) simulations informed by patient-specific transthoracic echocardiography (TTE) and blood pressure (BP) measurements, were incorporated into the forward penalty stress analysis. Aortic growth rates were quantified and visualized within the 3D TBAD geometries using the initial baseline and follow-up scans. Linear mixed-effects regression analyses were performed to evaluate the spatial correlations between biomechanical markers (structural wall stress, wall shear stress, and pressure) and aortic growth rates.ResultsUtilizing initial baseline CTA, TTE, and BP data, the forward penalty analyses revealed hemodynamic and structural mechanics insights of acute uncomplicated TBADs. The linear mixed-effects model indicated that the fixed-effect association between structural wall stress and aortic growth rate distributions was statistically significant (p=0.039), which demonstrated that aortic segments experiencing high wall stress exhibited rapid growth. Fixed-effect associations were not significant when predicting growth rate using wall shear stress (p=0.86) or pressure (p=0.61) distributions. Significant Pearson correlation coefficients (p<0.05) were observed between structural wall stress and aortic growth rate in all patients.ConclusionHigh structural wall stress was associated with regions of high aortic growth rates, while false lumen thrombosis was associated with low wall stress. Structural wall stress derived from the forward penalty approach may be a novel predictor of aortic growth rate and failure of optimal medical therapy in acute TBAD.

Trends and Updates in the Management and Outcomes of Acute Uncomplicated Type B Aortic Dissection.

Uncomplicated type B aortic dissections was regarded benign and treated with optimal medical therapy (OMT). However, studies showed highly unpredictable of disease progression, which suggested the need of earlier intervention. To search for features associated with worse outcomes with OMT is important due to risk of intervention. We investigated mortality and aortic remodeling between aggressive (OMT and pre-emptive endovascular intervention) and conservative therapy (OMT and necessary operations). Retrospective analysis was performed in acute and subacute uncomplicated type B dissections patients, including typical aortic dissection, intramural hematoma and penetrating atherosclerotic ulcer, diagnosed between June 2005 and May 2021. Patients with Marfan, traumatic, iatrogenic, zone 0 (ascending aorta) involvement, and maximal aortic diameter > 45mm were excluded. Patients are classified according to initial management. 77 and 33 patients in the aggressive and conservative groups were included respectively. There was no differences in baseline clinical and radiological characteristics between them. During mid-term follow-up (median 62.5 months), there was no difference in the mortality but the incidence of 30-day acute kidney injury was significantly higher in aggressive group. Positive aortic remodeling was noted in aggressive group, with development to complete or incomplete false lumen thrombosis (p < 0.01). Aggressive pre-emptive endovascular therapy though has acceptable outcomes and positive aortic remodelling in early uncomplicated type B dissection with maximal aortic diameter ≤ 45mm. However, it could not translate into better mid-term survival than conservative therapy, but with higher risk of 30-day acute kidney injury. Aggressive pre-emptive endovascular intervention should be cautious in these patients.

Objective: To develop a nomogram based on the monocyte-to-lymphocyte ratio (MLR) for predicting the risk of aortic-related adverse events within 30 days in patients with acute uncomplicated type B aortic intramural hematoma. Methods: This single-center retrospective cohort study screened consecutive patients with acute uncomplicated type B aortic intramural hematoma treated at the Emergency and Cardiovascular Medicine Departments of the General Hospital of the Northern Theater Command from April 2018 to April 2024. Patients were divided into two groups based on the optimal MLR cut-off value for predicting aortic-related adverse events: low MLR and high MLR group. MLR was defined as the ratio of monocytes to lymphocytes. Aortic-related adverse events were defined as a composite of aortic-related death or aortic intramural hematoma progression (including aortic dissection and penetrating aortic ulcers) within 30 days. The receiver operating characteristic (ROC) curve identified the optimal MLR cut-off value. Multivariate logistic regression was used to identify independent predictors of aortic-related adverse events within 30 days, based on which nomogram models were constructed: the clinical characteristics model and the clinical characteristics-MLR model. The DeLong test was used to evaluate the diagnostic performance of different risk models. The additional predictive value of MLR was assessed using the net reclassification index (NRI) and integrated discrimination improvement (IDI). Results: A total of 332 patients were included, of whom 217 were male (65.4%), with an average age of (64.3±9.4) years. A total of 107 aortic-related adverse events occurred during the 30-day follow-up period. The optimal cut-off value for MLR was 0.529. There were 189 cases in the low MLR group (MLR<0.529) and 143 cases in the high MLR group (MLR≥0.529). The rate of aortic-related adverse events was higher in the high MLR group compared to the low MLR group (44.1% (63/143) vs. 23.3% (44/189), P<0.001), mainly due to a higher rate of progression to aortic dissection (9.8% (14/143) vs. 1.1% (2/189), P<0.001) and penetrating aortic ulcers (31.5% (45/143) vs. 20.6% (39/189), P=0.025). Multivariate analysis identified diabetes (OR=0.25, 95%CI 0.08-0.78, P=0.017), anemia (OR=3.45, 95%CI 1.28-9.27, P=0.014), maximum descending aorta diameter (OR=1.08, 95%CI 1.02-1.15, P=0.007), ulcer-like projections (OR=4.04, 95%CI 2.26-7.24, P<0.001), and MLR (OR=6.61, 95%CI 2.50-17.46, P<0.001) as independent predictors of aortic-related adverse events during the 30-day follow-up period. The clinical characteristics model includes diabetes, anemia, ulcer-like projections and maximum diameter of the descending aorta, and the clinical characteristics-MLR model includes the above clinical characteristics and MLR. The results of the DeLong test showed that the clinical characteristic-MLR model demonstrated a higher area under the ROC curve compared to the clinical characteristic model alone (0.784 (95%CI 0.736-0.841) vs. 0.742 (95%CI 0.691-0.788), P=0.031). The continuous NRI was 0.461 (95%CI 0.237-0.685, P<0.001) and the IDI was 0.077 (95%CI 0.043-0.112, P<0.001), indicating that the inclusion of the MLR in the model significantly improved the predictive accuracy. Conclusion: The integration of MLR with other clinical characteristics improves the early identification of high-risk patients with acute uncomplicated type B aortic intramural hematoma, optimizing clinical decisions and improving patient outcomes.

Endovascular Repair vs Medical Therapy for Uncomplicated Acute Type B Dissection: Aortic Remodeling

This study aims to develop and validate a nomogram based on the Systemic Inflammatory Response Index (SIRI) to predict short-term aortic-related adverse events (ARAEs) in patients with acute uncomplicated Type B intramural hematoma (IMH). We retrospectively analyzed 332 patients diagnosed with acute uncomplicated Type B IMH between April 2018 and April 2024. Patients were categorized into the stable group (N=225) and the exacerbation group (N=107) based on the occurrence of ARAEs within 30-day observation period. SIRI was calculated using neutrophil, monocyte, and lymphocyte counts. ARAEs were defined as death related to aortic disease, and the progression of IMH to aortic dissection or penetrating aortic ulcer. The nomogram was developed incorporating SIRI and other significant clinical variables. The model's performance was evaluated using the area under the curve (AUC), calibration curves, decision curve analysis (DCA), and net reclassification index (NRI). Among the 332 patients, 217 were male (65.4%), with a mean age of 64.3±9.4 years. Multivariate logistic regression and LASSO regression analyses identified SIRI, anemia, diabetes, maximum diameter of aortic diameter (MDAD), and ulcer like projection (ULP) as independent predictors of ARAEs. Two nomogram models were developed: the Clinical model, including anemia, diabetes, MDAD, and ULP; and the Clinical-SIRI model, incorporating SIRI to the Clinical model. The Clinical-SIRI model demonstrated higher predictive accuracy, with an AUC of 0.788 (95% CI: 0.740-0.831), compared to the Clinical model's AUC of 0.742 (95% CI: 0.691-0.788, P = 0.012). SIRI improved predictive accuracy, as shown by a continuous NRI of 0.521 (95% CI: 0.301-0.743). Calibration curves and DCA further supported the clinical utility of the Clinical-SIRI model. The SIRI-based nomogram is a valuable prognostic tool for predicting short-term ARAEs in patients with acute uncomplicated Type B IMH.

Midterm outcomes of thoracic endovascular aortic repair versus optimal medical therapy for uncomplicated acute type B dissection.

Introduction: Medical management is recommended for patients with acute uncomplicated type B aortic dissection (TBAD), with operative intervention reserved for complicated cases. There is little research focused on sex differences in outcomes in patients with TBAD managed medically. Research Question: What is the impact of patient sex on in-hospital outcomes and readmissions for TBAD in patients who are managed medically? Methods: Hospitalizations of adults with a diagnosis of TBAD were identified using the 2016-2019 Nationwide Readmissions Database. TBAD diagnosis was deduced by inclusion of dissection of thoracic or thoracoabdominal aorta and exclusion of presumed type A aortic dissection based on prior studies. Hospitalizations associated with endovascular or open repair were excluded. Multivariable logistic regression modeling was used to investigate the association of sex with in-hospital mortality. A Cox proportional hazards model was used to assess the association between sex and readmission rates. Results: There were 52,269 TBAD hospitalizations (58% men). Compared to men, women were older (median age 72 vs 65 years), had higher in-hospital mortality (11.5% vs 8.5%), shorter median length of stay (3.95 vs 4.23 days), lower median total charges ($53,461 vs $63,655), and decreased rates of elective admissions (6.4% vs 8.2%) (all p&lt;0.05). Despite similar rates of hypertension, higher rates of atherosclerotic disease and risk factors in men, including coronary artery disease, obesity, and smoking, and decreased rates of hospital-related complications in women, including acute kidney injury, women experienced increased adjusted in-hospital mortality (odds ratio: 1.16; 95% CI, 1.06-1.27). However, there were no sex differences in readmission risk at 30, 90, and 180 days, perhaps reflecting a survivor bias. Conclusions: Women with TBAD who were managed medically experienced higher in-hospital mortality than men despite lower rates of atherosclerotic disease and risk factors. Prior research has demonstrated sex-specific differences in demographics and presenting TBAD clinical characteristics, including older age in women, varied signs/symptoms, and delays in diagnosis in women. We speculate that these features may contribute to the worse immediate outcomes observed in women. Further data are needed to delineate additional causes of adverse acute outcomes in women managed medically, including condition- (imaging and anatomic features) and medication-specific factors.

Introduction: Thoracic endovascular aortic repair (TEVAR) has emerged as a promising treatment option for patients with type B aortic dissection (TBAD). However, there is a lack of evidence regarding the long-term morbidity of initial TEVAR compared to optimal medical therapy (OMT) in acute uncomplicated TBAD (uTBAD). Objective: To evaluate real-world data(RWD) on the long-term outcome of Japanese patients with acute uTBAD using a nationwide claims database. Methods: This retrospective cohort study utilizes JMDC, a nationwide claims database under Japan's universal healthcare system. We included patients who were initially hospitalized with a diagnosis of acute TBAD. We defined acute uTBAD by excluding those who died within one month, suffered aortic rupture, traumatic thoracic aortic injury, underwent open-chest surgery, experienced stroke or paralysis, or had less than six months of history in the JMDC. Patients who underwent TEVAR within three months of the index hospitalization (TEVAR group) were compared with those who received optimal medical therapy (OMT group). Propensity score (PS) matching was performed based on age, sex, and year of hospitalization. Using the Kaplan-Meier method, we calculated the cumulative rate of all-cause mortality and aorta-related events. Results: Of 18,445 patients diagnosed with aortic disease between January 2005 and December 2020, 641 were included in the study (OMT group: n=580, TEVAR group: n=61). After PS-matching, demographics of the groups (OMT_PSM: n=183 vs. TEVAR_PSM: n=61) were female (12.6% vs. 13.1%), median age (54 years [IQR, 48-60] vs. 54 years [IQR, 50-61]) and follow-up time (18 months [8-32] vs. 19 months [9-32]), respectively. Kaplan-Meier curves for the aortic-related events (Figure1, 2) are shown as long-term outcomes. Conclusions: This study successfully demonstrated that the estimated 5-year aortic-related event rate in acute uTBAD patients undergoing OMT is approximately 20%, demonstrating the relevance of the RWD source. However, the number of death events in the TEVAR and OMT groups was not sufficient to provide statistical power. Therefore, further studies are warranted to evaluate the long-term prognosis of initial TEVAR for uTBAD.

The treatment of acute type B aortic dissection (ATBAD) is currently a challenge for vascular surgeons, because of the early morbidity and mortality rates and the high risk of late aortic events up to 50% at 5 years. This study presents the initial outcomes of ATBAD treatment using optimal medical therapy alone or combined with proximal entry tear stent-graft coverage. Additionally, it provides an analysis of the evolution of the aortic diameter and its clinical consequences during the chronic phase in each group. Conducted as a retrospective, single-center study, we enrolled all consecutive ATBAD patients (n=130) treated between 2008 and 2020. The primary analysis studies the entire patient cohort based on their initial management approach, namely, medical treatment alone for uncomplicated ATBAD (n=67) or combined with stent-graft entry tear coverage (n=63). We also conducted a subgroup analysis to investigate factors associated with disease progression in the medical management group. Median follow-up was 29.5 months. During this time aneurysmal evolution was observed in: 42.4% of cases in the medical group compared with 21.8% in the stent-graft group, primarily affecting the thoracic aorta. The stent-graft group exhibited significant aortic remodeling, with a decrease in false lumen (FL) and thoracic aortic diameters. Initial aortic diameter ≥40 mm and FL ≥22 mm were independent risk factors for aneurysmal degeneration. Five-year survival was consistent at 76.1% in both groups. This study confirms the safety and efficacy of stent-graft entry tear coverage for ATBAD. Initial thoracic endovascular aortic repair (TEVAR) appears to reduce late aortic events by promoting aortic remodeling. Considering TEVAR's safety and potential to prevent late aortic complications, it may be considered for uncomplicated ATBAD patients with an initial aortic diameter ≥40 mm or an FL ≥22 mm. This study validates the efficacy and safety of using endovascular stent grafts to seal the proximal entry tear in cases of acute type B aortic dissections, compared to optimal medical therapy. Aortic remodelling significantly benefits from endovascular stent graft coverage of the proximal entry tear. Given the heightened risk of late aortic events observed in the medical therapy cohort, there appears to be a necessity for including endovascular interventions in the management of uncomplicated acute type B aortic dissections, particularly when aortic diameter is ≥40 mm and false lumen diameter is ≥22 mm.

Volumetric analysis of acute uncomplicated type B aortic dissection using an automated deep learning aortic zone segmentation model

Outcomes of Patients with Acute Type B Aortic Dissection and High-Risk Features

Proximal Entry Closure Through TEVAR in High-Risk Features of Uncomplicated Acute Type B Aortic Dissection

Kiosk 4R-TA-03 - False Lumen Regurgitation FBaction, Energy Loss in Aorta and Wall Shear Stress Measured by 4d-flow -MRI in Predicting Expansion of Acute Uncomplicated Type B Aortic Dissection - A Prospective Study

False lumen regurgitation fraction and energy loss in the aorta measured using four-dimensional flow MRI to predict expansion of acute uncomplicated type B aortic dissection: a prospective study

IntroductionIn acute type B aortic dissection (TBAD) patients, thoracic endovascular aorta repair (TEVAR) and best medical treatment (BMT) have both been employed for the clinical management of this condition. The relative efficacy of TEVAR and BMT when used to manage cases of acute uncomplicated TBAD, however, remains to be clarified.AimTo conduct a pooled meta-analysis comparing acute uncomplicated TBAD patient outcomes associated with primary TEVAR or BMT treatment.Material and methodsRelevant articles published up to July 2023 were identified by searching the Web of Science, PubMed, and Wanfang databases. Pooled analyses of endpoints from these studies were then conducted.ResultsSix relevant studies were included in this meta-analysis, involving 522 and 535 patients who underwent TEVAR and BMT treatment, respectively. No significant differences were observed between these two groups with respect to pooled hospitalization duration, re-intervention rates, early mortality, organ failure incidence, stroke incidence, or the incidence of retrograde type A dissection (p = 0.89, 0.12, 0.09, 0.36, 0.09, and 0.95, respectively). TEVAR, however, was associated with significantly better pooled thrombosed/obliterated false lumen, late mortality, aorta-related mortality, and rupture rates relative to BMT (p = 0.00001, 0.002, 0.0001, and 0.04, respectively). TEVAR was associated with a 7% pooled type I endoleak incidence rate. Endpoints exhibiting significant heterogeneity included hospitalization duration, thrombosed/obliterated false lumen rates, and rupture rates (I2 = 96%, 73%, and 61%, respectively).ConclusionsWhile TEVAR and BMT yield similar short-term outcomes for acute uncomplicated TBAD patients, TEVAR may be associated with a better long-term patient prognosis.

The Role of Endovascular Repair Timing in Uncomplicated Acute Type B Intramural Hematoma Management