Outcomes Of Acute Aortic Dissection Research Articles

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.

Population-Based Study of Incidence and Outcome of Acute Aortic Dissection and Premorbid Risk Factor Control

Background— Acute aortic dissection is a preventable life-threatening condition. However, there have been no prospective population-based studies of incidence or outcome to inform an understanding of risk factors, strategies for prevention, or projections for future clinical service provision. Methods and Results— We prospectively determined incidence and outcomes of all acute aortic dissections in a population of 92 728 in Oxfordshire, United Kingdom, from 2002 to 2012. Among 155 patients with 174 acute aortic events, 54 patients had 59 thoracoabdominal aortic dissections (52 incident events: 6/100 000, 95% confidence interval, 4–7; 37 Stanford type A, 15 Stanford type B; 31 men, mean age=72.0 years). Among patients with type A incident events, 18 (48.6%) died before hospital assessment (61.1% women). The 30-day fatality rate was 47.4% for patients with type A dissections who survived to hospital admission and 13.3% for patients with type B dissections, although subsequent 5-year survival rates were high (85.7% for type A; 83.3% for type B). Even though 67.3% of patients were on antihypertensive drugs, 46.0% of all patients had at least 1 systolic BP ≥180 mm Hg in their primary care records over the preceding 5 years, and the proportion of blood pressures in the hypertensive range (>140/90 mm Hg) averaged 56.0%. Premorbid blood pressure was higher in patients with type A dissections that were immediately fatal than in those who survived to admission (mean/standard deviation pre-event systolic blood pressure=151.2/19.3 versus 137.9/17.9; P <0.001). Conclusions— Uncontrolled hypertension remains the most significant treatable risk factor for acute aortic dissection. Prospective population-based ascertainment showed that hospital-based registries will underestimate not only incidence and case fatality, but also the association with premorbid hypertension.

Acute Aortic Dissection in China

The clinical profiles and outcomes of acute aortic dissection (AAD) have not been evaluated in China. We retrospectively analyzed, from January 1, 2008 to December 31, 2011, the data from 1,812 patients (mean age 51.1 ± 10.9 years; 77.5% men) with AAD (726 with type A and 1,086 with type B) from 19 large hospitals. Most patients had hypertension and presented with an abrupt onset of chest and/or back pain. Patients with type A AAD were more likely to present with typical symptoms and signs. Computed tomography was the most common initial imaging modality, used in 76.3% of patients with an AAD. The overall in-hospital mortality rate was 17.7%, with most of the deaths occurring within the first week. Surgery was used in 75.3% of patients with type A AAD. The mortality in this cohort was 33.8%. Endovascular treatment was performed in 76.1% of patients with type B AAD. The mortality rate was 2.2%. Multivariate analysis showed that hypertension (odds ratio 2.80, p <0.001), Marfan syndrome (odds ratio 1.76, p = 0.017), anterior chest pain (odds ratio 1.62, p = 0.004), abdominal pain (odds ratio 1.51, p = 0.041), migrating pain (odds ratio 1.56, p = 0.04), and arch vessel involvement (odds ratio 1.70, p <0.001) were predictive factors for increased in-hospital mortality in patients with an AAD. In conclusion, our study has provided insight into the current profiles and outcomes of AAD in China. This knowledge might be useful for clinicians when diagnosing and treating these patients.

Abstract 16892: Trends in the Presentation, Diagnosis and Outcomes of Acute Aortic Dissection Over 15 Years, From the International Registry of Acute Aortic Dissection (IRAD).

Introduction/Purpose: To examine trends in patient presentation, diagnosis and outcomes of acute aortic dissection over 15 years since the original report from the International Registry of Acute Aortic Dissection (IRAD). Methods: Patient data were collected at 28 international referral centers from 1996 up to the present. Trends were analyzed among 3275 patients divided according to date of enrollment into 6 equal groups and by Type: A (n=2110) or B (n=1165). Results: There was no change over time in the presenting complaints of severe or worst ever pain for Type A and Type B (90% and 96%, respectively), or in the incidence of chest pain ( 80% in Type A and 70% in Type B, respectively), with considerable overlap in chest vs. back pain between types. The report of pulse deficits did not change over time, present in 30% of Type A patients. Normal chest X-ray on presentation increased in Type A acute aortic dissection (AoD) from 13.7% to 31.3% over time (p-value for trend &lt;0.001). In Type B the report of normal chest X-ray increased from 19.9% to 40.9% (p-value for trend &lt;0.001). There were significant trends in initial imaging modalities for Type A: increased use of CT (from 49.4% to 71.6%, p-value for trend &lt;0.001) and decreased use of TEE (from 45.3% to 25.4%, p-value for trend &lt;0.001). For Type B, use of CT increased from 77.2% to 88.4% (p-value for trend .013). A decrease in overall mortality over time was significant for both Type A and Type B patients (see graph). Surgical mortality in Type A patients fell from 25.3% to 16.5% (p-value for trend 0 .003). Conclusions: No significant difference was seen over time in pain severity, chest pain, and presence of pulse deficits. The incidences of a normal chest X-ray, originally thought to be uncommon in dissection cases, increased over time to 30% in Type A and 40% in Type B AoD. Use of CT as the initial imaging modality increased for both Type A and Type B. Lastly, a significant decrease in overall mortality was seen for both Type A and Type B patients.

動脈硬化性大動脈瘤を合併した大動脈解離の治療戦略と転帰

動脈硬化性大動脈瘤に合併した大動脈解離の治療戦略および治療成績に関して，1994年1月から2009年12月までに経験した228例の急性大動脈解離のうち，動脈硬化性大動脈瘤を合併した30例を対象としてretrospectiveに検討した．大動脈解離はStanford A型5例，B型25例であり，合併する大動脈瘤は腹部大動脈置換術後9例，上行大動脈瘤1例，弓部大動脈瘤6例，下行大動脈瘤2例，胸腹部大動脈瘤3例，腹部大動脈瘤9例であった．大動脈瘤と大動脈解離の関係から以下の3群に分類すると，大動脈瘤に対する人工血管置換術後に大動脈解離が発生したGroup 1が9例，大動脈瘤と大動脈解離が異所性に存在するGroup 2が8例，大動脈瘤と大動脈解離が接して存在するGroup 3が13例であった．大動脈破裂やmalperfusionがなければ基本的にはどのGroupに対しても，Stanford A型の場合は急性期に上行あるいは弓部置換術を，Stanford B型の場合は急性期には保存的療法を行い，それぞれ合併する大動脈瘤の径が大きい場合は慢性期に大動脈瘤手術を追加する方針で治療した．その結果，Group 3の来院時すでに大動脈解離が破裂していた1例と虚血性腸炎の1例が病院死亡となったが，全Groupにおいて急性期治療中の大動脈破裂および遠隔期大動脈関連死亡は認めなかった．合併する大動脈瘤が大きくても，破裂していなければ急性期手術を可及的に回避し，解離発生からできるだけ間隔をあけて大動脈瘤手術を行うという，我々の治療方針で早期治療成績および遠隔成績は概ね良好な結果であった．

Pregnancy in a Marfan patient with pre-existing aortic dissection

In women with Marfan syndrome pregnancy increases the risk of aortic dissection. There are a number of articles reporting the outcome of acute aortic dissection during pregnancy in this patient group. In contrast, only scarce information is available concerning pregnancy in patients with pre-existing chronic aortic dissection. We report the case of a pregnant Marfan syndrome patient with pre-existing chronic aortic dissection that showed a favourable maternal and fetal outcome.

Improved survival of surgery for acute type A aortic dissection: impact of noninvasive diagnosis and hemostatic surgical management.

In the past decade, progress in cardiovascular technology has been incorporated into the surgical treatment of acute type A dissection resulting in remarkable improvement. Factors in this progress encompass rapid noninvasive diagnosis, intraoperative introduction of aprotinine, surgical glue, sealed grafts, and refined surgical technique. The objective of this study is to identify which factors contributed to the improvement of the surgical outcome of acute type A dissections. Between January 1989 and February 2001, 78 consecutive patients had emergency surgeries for acute type A dissection. The initial 31 patients (group I) received preoperative angiography, when possible. Since 1996, the next 47 patients (group II) have received noninvasive rapid diagnosis with hemostatic surgical management. This included aggressive proximal resection and judicious use of gelatin resorcine formol glue and felt strips. Between the two groups, in-hospital mortality and morbidity, incidence of neurological complications, late survival and cardiovascular events were compared. Risk factors for in-hospital death were investigated with univariate and multivariate analysis. The in-hospital mortality was significantly improved in group II (4.3%) compared with group I (29.0%). Overall mortality was 14.1%. Multivariate analysis revealed preoperative limb ischemia and delayed timing of operation (> 3 hours after arrival) as independent risk factors for in-hospital death. Late survival at 5 years was 61.5+/-7.5%. Between the two groups there was no significant difference in late survival or cardiovascular events. Immediate surgical intervention, using rapid noninvasive diagnosis with hemostatic management, substantially improves the surgical outcome of acute aortic dissection.

Trends in management and outcomes of acute aortic dissection: Lessons learned from the first 1,000 patients enrolled in the International Registry of Acute Aortic Dissection (IRAD)

Trends in management and outcomes of acute aortic dissection: Lessons learned from the first 1,000 patients enrolled in the International Registry of Acute Aortic Dissection (IRAD)

Organ malperfusion in acute aortic dissection.

Organ malperfusion in aortic dissection can precipitate a serious condition. The strategy of treatment for it has been controversial. We have focused on the strategy and outcome of acute aortic dissection with organ malperfusion. Between January 1995 and December 1998, 134 acute aortic dissection patients were admitted. There were 73 males (65.4 +/- 8.0 years old) and 61 females (66.7 +/- 7.4 years old). There were 83 patients of Stanford type A, and 51 patients of type B. Of them, 24 patients (17.9%) were complicated by organ malperfusion. The brain was affected in 4, the heart in 5, the spinal cord in 2, the liver in 1, the intestine in 1, the kidney in 4, and the lower extremities in 10 patients. Our management strategy for a patient with malperfusion in acute aortic dissection was that the antecedent operation was initially mandatory, and central grafting was secondarily considered. Refusal of operation or lethal conditions excluded 8 of the 24 patients from operation. An antecedent operation was mandatory in eight of the remaining 16 patients. The overall mortality was 33.3% (8/24 patients), and operative mortality was 31.3% (5/16 patients) in the patients with malperfusion. The overall mortality was 11.8% (13/110 patients), and the operative mortality was 11.1% (9/81 patients) in the patients without malperfusion. Organ malperfusion is a major component in the management and treatment of acute aortic dissection. Only an appropriate strategy and therapy could result in a satisfactory outcome.