Outcomes Of Acute Aortic Dissection Research Articles

Incidence, presentation and outcome of acute aortic dissection: results from a population-based study

ObjectivesTo describe the incidence of acute aortic dissection in a clearly defined population, to assess onset symptoms and admission biochemical marker levels and to analyse variables potentially associated to mortality.MethodsMedical...

Usefulness of Computed Tomography Parameters in Predicting the Clinical Outcomes of Acute Aortic Dissection

Acute aortic dissection is a potentially life-threatening condition among patients presenting with chest pain to emergency department. Without a prompt diagnosis and treatment, it carries high mortality and morbidity. Computed tomography (CT) of thorax and abdomen is one of the commonly used non-invasive investigation modalities for diagnosis of acute aortic dissection. Apart from making a diagnosis, there are a number of parameters in the CT images that may be helpful in providing prognostic information. In this study, prognostic values of these parameters in predicting both short term and intermediate term clinical outcomes of acute aortic dissection will be evaluated. Methods and Results

Simple Death Risk Models to Predict In-hospital Outcomes in Acute Aortic Dissection in Emergency Department.

ObjectiveWe sought to find a bedside prognosis prediction model based on clinical and image parameters to determine the in-hospital outcomes of acute aortic dissection (AAD) in the emergency department.MethodsPatients who presented with AAD from January 2010 to December 2019 were retrospectively recruited in our derivation cohort. Then we prospectively collected patients with AAD from January 2020 to December 2021 as the validation cohort. We collected the demographics, medical history, treatment options, and in-hospital outcomes. All enrolled patients underwent computed tomography angiography. The image data were systematically reviewed for anatomic criteria in a retrospective fashion by three professional radiologists. A series of radiological parameters, including the extent of dissection, the site of the intimal tear, entry tear diameter, aortic diameter at each level, maximum false lumen diameter, and presence of pericardial effusion were collected.ResultsOf the 449 patients in the derivation cohort, 345 (76.8%) were male, the mean age was 61 years, and 298 (66.4%) had a history of hypertension. Surgical repair was performed in 327 (72.8%) cases in the derivation cohort, and the overall crude in-hospital mortality of AAD was 10.9%. Multivariate logistic regression analysis showed that predictors of in-hospital mortality in AAD included age, Marfan syndrome, type A aortic dissection, surgical repair, and maximum false lumen diameter. A final prognostic model incorporating these five predictors showed good calibration and discrimination in the derivation and validation cohorts. As for type A aortic dissection, 3-level type A aortic dissection clinical prognosis score (3ADPS) including 5 clinical and image variables scored from −2 to 5 was established: (1) moderate risk of death if 3ADPS is <0; (2) high risk of death if 3ADPS is 1–2; (3) very high risk of death if 3ADPS is more than 3. The area under the receiver operator characteristic curves in the validation cohorts was 0.833 (95% CI, 0.700–0.967).ConclusionAge, Marfan syndrome, type A aortic dissection, surgical repair, and maximum false lumen diameter can significantly affect the in-hospital outcomes of AAD. And 3ADPS contributes to the prediction of in-hospital prognosis of type A aortic dissection rapidly and effectively. As multivariable risk prediction tools, the risk models were readily available for emergency doctors to predict in-hospital mortality of patients with AAD in extreme clinical risk.

Influence of Abdominal Aortic Calcification on the Distal Extent and Branch Blood Supply of Acute Aortic Dissection

This study aimed to investigate the influence of abdominal aortic calcification on the distal extent, blood supply, and mid-term outcomes of acute aortic dissection (AAD). This single-centre retrospective study was conducted from August 2014 to May 2021. The aortic calcification index was used to evaluate abdominal aortic calcification. The standardized method provided by the Society for Vascular Surgery was used to evaluate the distal extent of AAD. Patients were divided into 3 groups as per the degree of calcification: no calcification (NC), low calcification (LC), and high calcification (HC). In a cohort of 723 patients, abdominal aortic calcification was present in 424 (58.6%) patients. The prevalence of coronary heart disease increased with the degree of calcification (NC versus LC versus HC: 8.4% vs. 9.5% vs. 19.3%, P<0.001). The aortic calcification index of the distal extent at zone 9 was higher than that of the distal extent exceeding zone 9 (P=0.001). The proportions of the NC, LC, and HC groups with distal extents exceeding zone 9 were 65.9% vs. 56.2% vs. 37.7%, P<0.001. In a multivariate logistics analysis, the calcification grade was a protective factor of distal extents exceeding zone 9 (P<0.001, odds ratio [OR]=0.592). Hypertension (P=0.019, OR=1.559) and D-dimer (P<0.001, OR=1.045) were risk factors. There was a higher proportion of branch-vessels on the abdominal aorta supplied by the true lumen in the calcification group (NC versus LC versus HC: 27.8% vs. 43.8% vs. 51.1%, P<0.001). There were no significant differences in the mid-term outcomes among the groups. Abdominal aortic calcification could limit the distal extent in patients with AAD and increase the proportion of branch-vessels on the abdominal aorta supplied by the true lumen.

Population-based incidence and outcomes of acute aortic dissection in Japan

Abstract Background The population-based incidence and outcomes of acute aortic dissection (AAD) are still unknown because some patients are already dead on arrival at the hospital, and the accurate diagnosis of AAD is difficult due to the low autopsy rate for patients with cardiopulmonary arrest outside of the hospital. We performed a population-based review of all patients with AAD in a well-defined geographical area in the southern part of Japan between 2016 and 2018. Methods Data of all patients with AAD at our Hospital, which performs medical care for 120,000 residents, were collected retrospectively. The emergency medical service is dedicated to the transfer of all patients in this area to the MPNH. For all patients who were dead on arrival, the diagnosis of AAD was made by autopsy imaging (AI) using computed tomography. The age-adjusted incidence and mortality per 100,000 population were calculated using the Japanese population distribution model in 2015. Results The total incidence of AAD was 79 (type A: 64.5%, n=51). Of those, 60.8% (31/51) of patients with type A and 21.4% (6/28) with type B were dead on arrival and diagnosed by AI. The 30-day mortality rates after the onset of AAD were 74.5% (38/51) in type A and 25.0% (7/28) in type B. Excluding the dead-on-arrival patients, the 30-day mortality rates were 35.0% (7/20) in type A and 4.5% (1/22) in type B. The age-adjusted incidence and mortality of AAD per 100,000 inhabitants were 17.3 (type A: 11.3, type B: 6.0) and 9.6 (type A: 8.4, type B: 1.2), respectively. Both values were significantly higher in men than in women. Conclusions The population-based survey of emergency medical care for AAD showed that the age-adjusted incidence of AAD was two-fold higher than in previous reports, and the actual mortality rates after AAD onset were markedly higher due to the high incidence of dead-on-arrival. Funding Acknowledgement Type of funding sources: None. Representative CT images of type A AAD

Differences in the clinical presentation, management, and in-hospital outcomes of acute aortic dissection in patients with and without end-stage renal disease

BackgroundFew studies have evaluated the clinical presentation, management, and outcomes of patients with end-stage renal disease (ESRD) presenting with acute aortic dissection (AAD) in real-world clinical practice. Thus, this study investigated the clinical characteristics, management, and outcomes of AAD patients with ESRD.MethodsA total of 217 patients were included. We evaluated the differences in the clinical features, management, and in-hospital outcomes of patients with and without a history of ESRD presenting with AAD.ResultsA history of ESRD was present in 71 of 217 patients. Patients with ESRD had atypical clinical manifestations (p < 0.001) and were more likely to be managed medically compared with patients without ESRD (p = 0.002). Hypertension and type B aortic dissection were significantly more common among patients with ESRD. Moreover, patients with ESRD had lower leucocyte and platelet counts than patients without ESRD in laboratory findings (p < 0.001). However, hospitalization days and in-hospital mortality were similar between the two groups (p > 0.05). Multivariate analysis identified Type A aortic dissection as an independent predictor of in-hospital mortality among patients without ESRD (OR, 13.68; 95% CI, 1.92 to 98.90; P = 0.006).ConclusionsThis study highlights differences in the clinical characteristics, management, and outcomes of AAD patients with ESRD. These patients usually have atypical symptoms and more comorbid conditions and are managed more conservatively. However, these patients have no in-hospital survival disadvantage over those without ESRD. Further studies are needed to better understand and optimize care for patients with ESRD presenting with AAD.

Population-based incidence and outcomes of acute aortic dissection in Japan.

The population-based incidence and outcomes of acute aortic dissection (AAD) are still unknown because some patients are already dead on arrival, and the accurate diagnosis of AAD is difficult due to the low autopsy rate. We performed a population-based review of all patients with AAD in a well-defined geographical area in Japan between 2016 and 2018. Data of all patients with AAD at Miyazaki Prefectural Nobeoka Hospital (MPNH), which performs medical care for 120 000 residents, were collected retrospectively. The emergency medical service is dedicated to the transfer of all patients in this area to the MPNH. For all patients who were dead on arrival, the diagnosis of AAD was made by autopsy imaging (AI) using computed tomography. The age-adjusted incidence and mortality per 100 000 population were calculated using the Japanese population distribution model in 2015. The total incidence of AAD was 79 (type A: 64.5%, n = 51). Of those, 60.8% (31/51) of patients with type A and 21.4% (6/28) with type B were dead on arrival and diagnosed by AI. The 30-day mortality rates were 74.5% (38/51) in type A and 25.0% (7/28) in type B. The age-adjusted incidence and mortality of AAD per 100 000 inhabitants were 17.6 (type A: 11.3, type B: 6.2) and 9.9 (type A: 8.4, type B: 1.5), respectively. The population-based survey of AAD showed that the age-adjusted incidence of AAD was two-fold higher than in previous reports, and the actual mortality rates were markedly higher due to the high incidence of dead-on-arrival.

Current status of the management and outcomes of acute aortic dissection in Japan: Analyses of nationwide Japanese Registry of All Cardiac and Vascular Diseases-Diagnostic Procedure Combination data.

Despite recent advances in the diagnosis and management, the mortality of acute aortic dissection remains high. This study aims to clarify the current status of the management and outcome of acute aortic dissection in Japan. A total of 18,348 patients with acute aortic dissection (type A: 10,131, type B: 8217) in the Japanese Registry of All Cardiac and Vascular Diseases database between April 2012-March 2015 were studied. Characteristics, clinical presentation, management, and in-hospital outcomes were analyzed. Seasonal onset variation (autumn- and winter-dominant) was found in both types. More than 90% of patients underwent computed tomography for primary diagnosis. The overall in-hospital mortality of types A and B was 24.3% and 4.5%, respectively. The mortality in type A patients managed surgically was significantly lower than in those not receiving surgery (11.8% (799/6788) vs 49.7% (1663/3343); p<0.001). The number of cases managed endovascularly in type B increased 2.2-fold during the period, and although not statistically significant, the mortality gradually decreased (5.2% to 4.1%, p=0.49). Type A showed significantly longer length of hospitalization (median 28 days) and more than five times higher medical costs (6.26 million Japanese yen) than those in type B. The mean Barthel index at discharge was favorable in both type A (89.0±22.6) and type B (92.6±19.0). More than two-thirds of type A patients and nearly 90% of type B patients were directly discharged home. This nationwide study elucidated the clinical features and outcomes in contemporary patients with acute aortic dissections in real-world clinical practice in Japan.

Impact of structural and process quality indicators on the outcomes of acute aortic dissection

The mortality of acute aortic dissection (AAD) remains high, and evidence-to-practice gaps exist in real-world treatment. We explored the first quality indicators (QIs) for AAD management and evaluated the associations between the achievement of these QIs and the outcome in a nationwide administrative database. A systematic search was performed to establish initial index items for QIs. An evaluation was performed through an expert consensus meeting using the Delphi method. We studied 18 348 patients who had AAD (type A: 10 131; type B: 8217) in the Japanese Registry of All Cardiac and Vascular Diseases database between April 2012 and May 2015. The associations between the achievement of QIs [categorized into tertiles (low, middle and high)] and in-hospital mortality were determined by multivariable mixed logistic regression analyses. We developed a total of 9 QIs (5 structural and 4 process). Lower achievement rates of QIs were significantly associated with higher in-hospital mortality in both types [type A = middle: odds ratio (OR) 4.03; 95% confidence interval (CI) 3.301-4.90; P < 0.001; low: OR 15.68; 95% CI 11.67-21.06; P < 0.001 vs high; type B = middle: OR 3.48; 95% CI 2.19-5.53; P < 0.001; low: OR 7.79; 95% CI 4.65-13.06; P < 0.001 vs high]. Various sensitivity analyses showed consistent results. High achievement rates of QIs were significantly associated with reduced in-hospital mortality. Evaluating each hospital's management using QIs would help to equalize treatment quality and demonstrate the evidence-to-practice gaps in real-world treatments for AAD.

P5599Prognostic impact of quality indicators on outcomes of acute aortic dissection in Japan

Abstract Background Despite recent advances in diagnosis and management, the mortality of acute aortic dissection (AAD) remains high. Purpose This study aims to develop quality indicators (QIs) for the management of AAD, and to evaluate the associations between QIs and outcomes of AAD in a Japanese nationwide administrative database. Methods A total of 18,348 patients suffered from AAD (Type A: 10,131, Type B: 8,217) in the Japanese Registry of All Cardiac and Vascular Diseases database between 2012 and 2015 were studied. A systematic review was performed to establish initial index items for QIs. Evaluation was performed through the expert consensus meeting using a Delphi method. Associations between developed QIs and the mortality were determined by multivariate mixed logistic regression analyses. Results A total of nine QIs (five structural and four processatic) were developed. Achievements of developed QIs (High: 7–9, Middle: 4–6, Low: 0–3) were significantly associated with lower in-hospital mortality even after adjustment for covariates in both type A (Middle: odds ratio [OR], 0.257; 95% confidence interval [CI], 0.211–0.312; P&lt;0.001; High: OR, 0.064; 95% CI, 0.047–0.086; P&lt;0.001 vs. Low) and type B (Middle: OR, 0.447; 95% CI, 0.338–0.590; P&lt;0.001; High: OR, 0.128; 95% CI, 0.077–0.215; P&lt;0.001 vs. Low). Additionally, achievements of structural and processatic QIs were consistently associated with reduced in-hospital mortality. QIs and in-hospital mortality Conclusions Developed QIs for AAD management were significantly associated with lower in-hospital mortality. Evaluation of each hospital's management with QIs could be helpful to equalize quality of treatment and to fill the evidence-to-practice gaps in the real-world treatment.

Outcome of acute aortic dissection presented with disorder of consciousness

Outcome of acute aortic dissection presented with disorder of consciousness

BODY MASS INDEX AND ACUTE AORTIC DISSECTION

Background: Obesity has been linked to many cardiovascular diseases, yet little is known about its impact on acute aortic dissection (AAD). We sought to assess the clinical manifestations, management and outcomes of AAD in relation to body mass index (BMI). Methods: We evaluated 2037 AAD patients

Insights from the International Registry of Acute Aortic Dissection

The International Registry of Acute Aortic Dissection (IRAD) was established in 1996 for the purpose of enrolling patients at large referral centres to assess the presentation, management and outcomes of acute aortic dissection (AAD). Data on presentation, diagnostic, management and outcomes were initially collected by 12 centres and then extended to 28 referral centres. All data of more than 5,000 cases were reviewed and analysed by the IRAD Coordinating Center at the University of Michigan. Since the first publication in 2000, IRAD investigators have reported a number of clinical observations, in more than 70 publications. This article will cover most of these points highlighting the findings of IRAD in patients with type A (with ascending aorta involvement) and type B (without ascending aorta involvement) AAD.

IP067. Influence of Gender on the Occurrence and Outcomes of Acute Aortic Dissection

IP067. Influence of Gender on the Occurrence and Outcomes of Acute Aortic Dissection

Presentation, Diagnosis, and Outcomes of Acute Aortic Dissection: Seventeen-Year Trends From the International Registry of Acute Aortic Dissection

Presentation, Diagnosis, and Outcomes of Acute Aortic Dissection: Seventeen-Year Trends From the International Registry of Acute Aortic Dissection

Abstract 19334: Management and Outcomes of Acute Retrograde Type A Aortic Dissection: Insights From the International Registry of Acute Aortic Dissection

Background: Presentations and outcomes of acute aortic dissection (AD) with an entry tear in the ascending aorta may differ from retrograde dissection with an entry tear in the descending aorta. However, guidelines recommend urgent surgical repair for both entities. Methods and Results: All patients with AD enrolled in the International Registry of Acute Aortic Dissection (IRAD) between 1996 and 2014 were analyzed. We identified 99 patients (67 men; 63.2±14.0 years) with an entry tear in the descending aorta and retrograde extension into the arch or ascending aorta. Overall, independent predictors of retrograde type A AD were increasing age(OR 1.0; 95% CI, 1.0 to 1.0; P=0.004), history of cocaine abuse (OR 4.9; 95% CI, 1.7 to 13.6; P=0.003), back pain at presentation (OR 2.1; 95% CI, 1.3 to 3.3; P=0.002), and non-white race (OR 0.4; 95% CI, 0.2 to 0.6; P&lt;0.001). During initial hospitalization, 44 of these patients were managed medically (MED), 33 with open surgery(SURG) and 22with endovascular therapy (ENDO). Patients in the SURG group presented with larger ascending aortic diameters than MED and ENDO patients (P=0.04). The majority of the MED (72.7%) and ENDO (86.4%) patients had AD extension confined to zone 1 (proximal arch, P&lt;0.001), whereas most of the SURG patients (71.8%) presented with AD extension into zone 0 (proximal to the innominate artery, P&lt;0.001). Early (30-day or in-hospital) mortality rates of the MED, SURG and ENDO groups were 9.1%, 18.2%, and 13.6%, respectively (P=0.51), with 5-year survival of 86.7%, 80.0%, and 90.9%, respectively (mean follow-up, 3.3 years, log rank P=0.67). A trend of favorable early mortality was observed in patients with retrograde extension till zone 1 (8.6%) versus into zone 0 (18.6%, P=0.14).Early mortality of patients with retrograde type A AD (12.9%) was lower than those with type A AD (20.0%, P=0.001), while 5-year survival was similar (86.8% and 89.5%, respectively, mean follow-up, 3.0 years, log rank P=0.96). Conclusion: There is a subset of patients with acute retrograde type A AD who can be managed non-operatively with acceptable short and long-term results. This implies that a selective approach may be reasonable, particularly among those with proximal extension limited to the arch distal to the innominate artery.

Presentation, Diagnosis, and Outcomes of Acute Aortic Dissection: 17-Year Trends From the International Registry of Acute Aortic Dissection

BackgroundDiagnosis, treatment, and outcomes of acute aortic dissection (AAS) are changing. ObjectivesThis study examined 17-year trends in the presentation, diagnosis, and hospital outcomes of AAD from the International Registry of Acute Aortic Dissection (IRAD). MethodsData from 4,428 patients enrolled at 28 IRAD centers between December 26, 1995, and February 6, 2013, were analyzed. Patients were divided according to enrollment date into 6 equal groups and by AAD type: A (n = 2,952) or B (n = 1,476). ResultsThere was no change in the presenting complaints of severe or worst-ever pain for type A and type B AAD (93% and 94%, respectively), nor in the incidence of chest pain (83% and 71%, respectively). Use of computed tomography (CT) for diagnosis of type A increased from 46% to 73% (p < 0.001). Surgical management for type A increased from 79% to 90% (p < 0.001). Endovascular management of type B increased from 7% to 31% (p < 0.001). Type A in-hospital mortality decreased significantly (31% to 22%; p < 0.001), as surgical mortality (25% to 18%; p = 0.003). There was no significant trend in in-hospital mortality in type B (from 12% to 14%). ConclusionsPresenting symptoms and physical findings of AAD have not changed significantly. Use of chest CT increased for type A. More patients in both groups were managed with interventional procedures: surgery in type A and endovascular therapy in type B. A significant decrease in overall in-hospital mortality was seen for type A but not for type B.

Outcomes in pregnant women with acute aortic dissections: a review of the literature from 2003 to 2013

BackgroundAcute aortic dissection in pregnant women is a rare but potentially life-threatening event. Our aim was to evaluate maternal and fetal outcomes of acute aortic dissection during pregnancy. MethodsWe conducted a review of literature of the PubMed database to identify publications related to pregnant women with acute aortic dissections during the period 2003–2013: 59 articles were included in the study. ResultsA total of 75 patients were included in the analyses. Stanford type A dissections were the most common form, accounting for 77% of all cases. The majority (78%) occurred in the third trimester and immediate postpartum period. Inherited connective tissue disorders were causative in 49% of patients. Maternal mortality was not statistical different between type A and type B dissections (21% vs. 23%), but fetal outcomes were worse in type B dissections (35% vs. 10.3%; P<0.05). Fetal mortality in type A dissections was dependent on the timing of aortic repair, with antepartum aortic repair associated with a higher mortality (36%). ConclusionDespite advances in diagnostic and surgical techniques, maternal and fetal mortalities in pregnant patients with aortic dissection remain high. Patients undergoing combined cesarean section with aortic repair had favorable fetal outcomes.

Clinical profiles and outcomes of acute aortic dissection in a predominantly Hispanic population

BackgroundAcute aortic dissection (AAD) is a life-threatening cardiovascular condition with high morbidity and mortality.We sought to assess clinical profiles as well as outcomes of AAD in a predominantly Hispanic population and to explore the relationship between this condition and uncontrolled/untreated hypertension in this community.Material/MethodsThis was a single-center, retrospective, cross-sectional study of patients admitted with AAD over a 10 years period.ResultsFifty-nine cases of AAD were included in the analysis. The group of Hispanics with AAD had more females (48.3%, p=0.002), more dyslipidemia and coronary artery disease (p=0.006 and 0.05, respectively), and a tendency to be older and have more hypertension and diabetes compared to non-Hispanics. Although 70.2% of all patients had hypertension, only 52.5% of them were being treated; of those, only 66.7% achieved optimal blood pressure control prior to presentation. Only 47.4% received beta-blockers for blood pressure control in the acute setting. Longer length of in-hospital stay was associated with older age, higher troponin and creatine kinase levels, and presence of hypertension. In-hospital death occurred in 10 (17%) patients and mortality was significantly associated with higher serum creatinine (p=0.01).ConclusionsHispanic patients with AAD were more likely to be female, of older age, and have more cardiovascular risk factors in comparison to non-Hispanics. In addition, significant under-treatment of hypertension in this population and underutilization of beta-blockers for blood pressure control in the acute settings was evident. Better prevention and timely treatment may improve outcomes for this condition in this population.

Population-Based Study of Incidence and Outcome of Acute Aortic Dissection and Premorbid Risk Factor Control: 10-Year Results From the Oxford Vascular Study

Hospital-based registries likely underestimate not only the incidence of acute aortic dissection but also its association with premorbid hypertension. The most significant treatable condition leading to acute aortic dissection remains uncontrolled hypertension.