Type B Aortic Dissection Patients Research Articles

Application of occlusive devices in endovascular repair of Stanford type B aortic dissection with insufficient landing zones

OBJECTIVES: Occlusion of intimal tear with occlusive devices is an alternative or adjuvant method for endovascular repair of Stanford type B aortic dissection (TBAD) with insufficient landing zones. This study aimed to evaluate the efficacy and safety of using occluders in highly selective TBAD patients inappropriate for conventional thoracic endovascular aortic repair (TEVAR). METHODS: All patients undergoing TEVAR between July 2009 and July 2015 were retrospectively reviewed and patients treated with only or adjuvant occlusive devices were included in the study. Demographic data, clinical characteristics, perioperative data, and follow-up were collected and analyzed. RESULTS: A total of 10 TBAD patients treated with occluders were included in the study. The mean age was 56.8 ± 12.7 years old and the majority of the patients were male (7/10). Only occluders were applied to seal the proximal tears in seven cases, while occluders combined with other endovascular techniques were used in three cases. No 30-day mortality operative reintervention was required in two cases. Eight patients were followed up for 10.0 ± 4.1 years and two cases were lost to follow-up. Three patients died during the follow-up period; one patient died of stroke, while the other two patients died due to noncardiovascular causes. One reintervention was performed due to endoleak 2 years after the surgery. CONCLUSIONS: The early and long-term outcomes of the 10 patients show that treating difficult aortic lesions unfit for traditional TEVAR with occluders is effective and safe. The technique may provide a treatment alternative in highly selective TBAD patients unfit for traditional TEVAR.

Does intensive blood pressure control benefit type B aortic dissection patients who undergoing surgical repair?

The aim of this research is to determine the optimum blood pressure (BP) control goal for hypertensive type B aortic dissection (TBAD) patients undergoing surgery. Between January 2019 and April 2021, 259 hypertensive TBAD patients undergoing surgery were included in the research. 98 patients received intensive BP control with a target of systolic BP (SBP) < 120mmHg, and 161 received standard BP control targeting SBP between 120 and 140mmHg. Clinical data from two groups were compared. Patients who received intensive BP control experienced a significantly higher incidence of acute kidney injury (AKI) postoperatively (21/98, 21.4% vs 14/161, 8.7%, p = 0.004). The intensive group took more anti-hypertensive drugs per day compared with the standard group (1.9 vs 1.5, p < 0.001). Triple-drug combination treatment was more frequent in the intensive group (38.8% vs 14.3%, p < 0.001), as were angiotensin-converting-enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB; 67.3% vs 44.7%, p 0.001), and thiazide-like diuretic (44.9% vs 18.0%, p < 0.001). Intensive BP control treatment increases the incidence of AKI and raises the utilization of the anti-hypertensive drug, but did not reduce the operative mortality and late mortality in TBAD patients undergoing surgical repair.

Prognosis and Remodeling after Endovascular Repair for Acute, Subacute, and Chronic Type B Aortic Dissection

Purpose: Thoracic endovascular aortic repair (TEVAR) for type B aortic dissection (TBAD) is already well introduced, but the best time point to perform TEVAR has not been defined. This study was to report mid- to long-term outcomes and aortic remodeling of TEVAR in patients with TBAD. Materials and Methods: In total, 318 TBAD patients from June 2001 to May 2016 were retrospectively reviewed. Patients were divided into 3 groups depending on interval between dissection onset to TEVAR: acute (0–7 days), subacute (8–30 days), and chronic (>30 days). Clinical and morphological data were collected and analyzed. Results: The follow-up aorta-related mortality rates in the 3 groups were 17.6%, 2.6%, 4.2%, and the proximal stent-induced new entry rates were 11.8%, 1.6%, 2.8%, respectively. Aortic remodeling was satisfied in both the acute and subacute group, but the false lumen diameter did not decrease (p>0.05) in the chronic group. Compared with the VIRTUE classification (acute, 0–14 days; subacute, 15–92 days; chronic, >92 days), mid- to long-term outcomes of patients within the first overlapped interval between the 2 classifications (8–14 days) were similar to that of subacute patients (15–30 days), while aortic remodeling of patients in the second overlapped interval (31–92 days) was similar to that of chronic patients (>92 days). Conclusions: This study suggests that TEVAR for subacute TBAD is associated with a low long-term rate of aorta-related death. Aortic remodeling of chronic dissections is not satisfactory. Additional results suggest that the subacute phase (8–30 days) may be the optimal time to perform TEVAR for uncomplicated TBAD.

Delivery of Optimum Management of Type B Aortic Dissection in the UK: Sum of All Fears!

Introduction: This review aims to summarise the current trend and practice for management of Type B aortic dissection (TBAD) across the UK. We also aim to highlight the service specification and configuration as well as the current portrayed outcomes published from different sources within the UK. Methods: We carried out a comprehensive literature search on multiple electronic databases including PUBMED, Scopus and EMBASE in order to collate all research evidence on TBAD service line in the UK. We also navigated through official reports published from different sources within the UK specifically highlighting aortic dissection. Results: The UK’s research into TBAD falls short when compared to international counterparts due to a lack of evidence related to TBAD incidence and outcomes. Some TBAD patients are managed at unspecialised centres and others are lost to follow-up. The UK’s vascular surgery workforce is expanding at a very slow rate and the specialised aortic units are consistently failing to meet the waiting time standards for treatment. Conclusions: Restructuring and service reconfiguration are imperative for outcome reporting for TBAD affected population cohort. TBAD should be centralised towards hospital with concentrated level of experience and expertise.

Prevention of distal stent graft-induced new entry after endovascular repair for type B aortic dissection: A retrospective cohort study

ObjectivesDistal stent graft-induced new entry (dSINE) can occur after thoracic endovascular aortic repair (TEVAR) for type B aortic dissection (TBAD). In this study we aimed to compare the effectiveness of restrictive bare stent (RBS), tapered stent graft (TSG), and non-TSG in TEVAR in preventing dSINE after a midterm follow-up. MethodsThis retrospective cohort study included patients with TBAD who underwent TEVAR (June 2010 to December 2018). The occurrence of dSINE during follow-up was examined. Predictors of dSINE were determined using Fine–Gray regression with death as the competing event. Survival was evaluated using Cox proportional hazards regression. ResultsFinally, 364 patients were included: 111 with non-TSG TEVAR, 125 with TSG TEVAR, and 128 with TEVAR with RBS. After 54.5 months, incidences of dSINE in the 3 groups were 12.61%, 4.80%, and 1.56%, respectively (P = .002). On Fine–Gray regression adjusted for clinically relevant covariates, the expansion mismatch ratio (subdistribution hazard ratio, 1.09; 95% CI, 1.07-1.12; P < .001) and complete false lumen thrombosis (subdistribution hazard ratio, 0.35; 95% CI, 0.13-0.94; P = .037) were identified as predictors of dSINE. The Cox proportional hazards regression analysis revealed that dSINE was not only a risk factor for aortic-related mortality (hazard ratio, 17.90; 95% CI, 3.27-98.12; P = .001), but also a predominant risk factor for all-cause mortality (hazard ratio, 4.91; 95% CI, 1.66-14.52; P = .004). ConclusionsdSINE can happen in TBAD patients who undergo TEVAR. Thus, long-term surveillance is crucial. TSG and RBS had lower expansion mismatch ratios, which might help prevent dSINE.

Racial disparities in presentation and short-term outcomes for patients with acute type B aortic dissection

ObjectiveRacial disparities in cardiovascular risk factors and disease outcomes have been well documented. A knowledge gap exists regarding the role that health maintenance plays in the development and outcomes of type B aortic dissection (TBAD). In the present study, we evaluated the comparative presentation and short-term outcomes of patients with TBAD across race. MethodsIn the present single-center, retrospective study, TBAD patients who had been admitted to the intensive care unit from 2015 to 2020 were identified. Patients who had self-identified as Black (n = 57) or White (n = 123) were included. The demographics, socioeconomic status, and pre-event health maintenance were compared between the two groups. Socioeconomic disadvantage was quantified using the area deprivation index (ADI). Management strategies included nonoperative and surgical repair. The outcomes assessed included 30-day mortality, hospital length of stay, and the APACHE II (acute physiology and chronic health evaluation) score. ResultsThe present study included 180 consecutive patients with TBAD. TBAD included complicated (n = 42) and uncomplicated (n = 138) cases, of which 79 had had high-risk features. Black patients were younger than were White patients (58.9 vs 67.6 years; P < .01) and were more likely to have end-stage renal disease (8.8% vs 0.8%; P = .01) and to present with anemia (10.5% vs 2.4%; P = .03). The TBAD anatomic features and management were similar in both groups. The rate of surgical intervention during hospitalization was 40% and 46% for the Black and White patients, respectively (P = .4). Black patients were more likely to be taking three or more hypertension agents (42.2% vs 16.4%; P = .005) and were less likely to be adherent to taking the prescribed agents (27.1% vs 6.7%; P < .001). Also, Black patients had fewer primary care physician visits before TBAD (P = .03) and more emergency department usage before TBAD (57.9% vs 26.9%; P < .001). Black patients had also had higher ADI scores (86.0 ± 14.6 vs 64.4 ± 21.3; P < .001). The median APACHE II score was the same for both Black and White patients (9 [interquartile range (IQR), 6-12] and 9 [IQR, 7-13], respectively; P = .7). The median hospital length of stay was identical for both groups (7 days; IQR, 5-13 days). The readmission rate was 24.5% for Black patients vs 15.5% for White patients (P = .16), with the 30-day mortality similar between the two groups (Black, 7.0%; White, 5.7%; P = .7). ConclusionsBlack patients had presented at a younger age but with similar dissection morphology, rate of anatomic high-risk features, and APACHE II scores. The fewer primary care physician visits, greater emergency department usage, and higher ADI scores suggested lower health maintenance for the Black patients. White patients with TBAD were also highly deprived of health maintenance compared with the national percentile, indicating that TBAD is a disease that affects vulnerable populations, regardless of race.

Association Between Preoperative Monocyte to High-Density Lipoprotein Ratio on In-hospital and Long-Term Mortality in Patients Undergoing Endovascular Repair for Acute Type B Aortic Dissection.

Aims: The monocyte to high-density lipoprotein ratio (MHR), a novel marker of inflammation and cardiovascular events, has recently been found to facilitate the diagnosis of acute aortic dissection. This study aimed to assess the association of preoperative MHR with in-hospital and long-term mortality after thoracic endovascular aortic repair (TEVAR) for acute type B aortic dissection (TBAD).Methods: We retrospectively evaluated 637 patients with acute TBAD who underwent TEVAR from a prospectively maintained database. Multivariable logistic and cox regression analyses were conducted to assess the relationship between preoperative MHR and in-hospital as well as long-term mortality. For clinical use, MHR was modeled as a continuous variable and a categorical variable with the optimal cutoff evaluated by receiver operator characteristic curve for long-term mortality. Propensity score matching was used to diminish baseline differences and subgroups analyses were conducted to assess the robustness of the results.Results: Twenty-one (3.3%) patients died during hospitalization and 52 deaths (8.4%) were documented after a median follow-up of 48.1 months. The optimal cutoff value was 1.13 selected according to the receiver operator characteristic curve (sensitivity 78.8%; specificity 58.9%). Multivariate analyses showed that MHR was independently associated with either in-hospital death [odds ratio (OR) 2.11, 95% confidence interval (CI) 1.16-3.85, P = 0.015] or long-term mortality [hazard ratio (HR) 1.78, 95% CI 1.31-2.41, P < 0.001). As a categorical variable, MHR > 1.13 remained an independent predictor of in-hospital death (OR 4.53, 95% CI 1.44-14.30, P = 0.010) and long-term mortality (HR 4.16, 95% CI 2.13-8.10, P < 0.001). Propensity score analyses demonstrated similar results for both in-hospital death and long-term mortality. The association was further confirmed by subgroup analyses.Conclusions: MHR might be useful for identifying patients at high risk of in-hospital and long-term mortality, which could be integrated into risk stratification strategies for acute TBAD patients undergoing TEVAR.

Aortic-Related Readmission After Thoracic Endovascular Aortic Repair for Type B Aortic Dissection Patients: A Single-Center Retrospective Study

This study aimed to investigate the characteristics of and risk factors for aortic-related readmission after thoracic endovascular aortic repair (TEVAR) for type B aortic dissection (TBAD). Data from TBAD patients who underwent TEVAR from 2009-2018 at a Chinese tertiary center were retrospectively collected and analyzed. Enrolled patients were categorized into 2 groups according to whether aortic-related readmission occurred during follow-up, which was defined as hospitalization at least once after the initial procedure due to events that were related to or caused by aortic dissection or the initial procedure. A total of 1 288 TBAD patients were enrolled, and 99 patients experienced aortic-related readmissions (7.7%), among whom chronic patients had the highest readmission rate (9.8%). The yearly proportion of readmission during the first year after initial procedure revealed a decreasing trend with a -9.7% annual percentage change. Seventy-one patients underwent reintervention (71.7%). Distal aneurysmal degeneration (43.7%) and distal stent graft-induced new entries (32.4%) were 2 major causes for reintervention. Fourteen patients in the reintervention subgroup underwent a second reintervention (19.7%). In-hospital mortality was 1.0% during the readmission and 14.3% during the second readmission. The overall survival was comparable between two groups (P = 0.93). This study highlighted the importance of surveillance after initial procedure for TBAD patients with potential risk factors for aortic-related readmission, and the predisposition of patients with reintervention to multiple readmissions deserves attention.

Neutrophil-to-Lymphocyte Ratio Facilitates Identification of Obstructive Sleep Apnea in Patients with Type B Aortic Dissection.

Purpose To determine whether the neutrophil-to-lymphocyte ratio (NLR) aids in the detection of obstructive sleep apnea (OSA) in patients with type B aortic dissection (TBAD). Methods 324 patients with TBAD or type B aortic intramural hematoma (TB-AIMH) underwent an overnight sleep study. We divided the eligible 256 studied subjects into three groups: group A (n = 109, TBAD patients with OSA), group B (n = 68, TB-AIMH patients with OSA), and group C (n = 79, TBAD patients without OSA). Baseline characteristics, biochemical and sleep parameters, and STOP-Bang questionnaire scores were collected. To assess the predictive efficacy of potential variables, multivariate logistic regression analysis and receiver operating characteristic (ROC) curves were used. Results The study found that about 58% of TBAD patients and 54% of TB-AIMH patients had OSA, a majority of whom had moderate to severe OSA (95.41% and 89.71%, respectively). In the comparison of sleep parameters between patients with TBAD and TB-AIMH, no other than apnea and hypopnea index (AHI) made a significant difference. The multivariate logistic regression analysis showed that neutrophil-to-lymphocyte ratio (NLR) (odds ratio (OR): 3.614, 95% confidence interval (CI): 2.273–5.748, and P < 0.05) and STOP-Bang scores (OR: 1.97, 95% CI: 1.34–2.90, and P < 0.05) were both independent predictors for OSA in patients with TBAD. ROC curves showed NLR had higher sensitivity (65% versus 59%) and specificity (86% versus 57%) for OSA than the STOP-Bang questionnaire. Furthermore, NLR was positively correlated with AHI through the Spearman test (r = 0.398 and P < 0.05). Conclusion NLR was an independent predictor of OSA in TBAD patients with higher sensitivity and specificity than the STOP-Bang questionnaire, and it was positively associated with AHI. NLR may aid in the diagnosis and risk stratification of OSA in TBAD patients.

Evaluation and verification of patient-specific modelling of type B aortic dissection

Quantitative assessment of the complex hemodynamic environment in type B aortic dissection (TBAD) through computational fluid dynamics (CFD) simulations can provide detailed insights into the disease and its progression. As imaging and computational technologies have advanced, methodologies have been developed to increase the accuracy and physiological relevance of CFD simulations. This study presents a patient-specific workflow to simulate blood flow in TBAD, utilising the maximum amount of in vivo data available in the form of CT images, 4D-flow MRI and invasive Doppler-wire pressure measurements, to implement the recommended current best practice methodologies in terms of patient-specific geometry and boundary conditions. The study aimed to evaluate and verify this workflow through detailed qualitative and quantitative comparisons of the CFD and in vivo data. Based on data acquired from five TBAD patients, a range of essential model inputs was obtained, including inlet flow waveforms and 3-element Windkessel model parameters, which can be utilised in further studies where in vivo flow data is not available. Local and global analysis showed good consistency between CFD results and 4D-MRI data, with the maximum velocity in the primary entry tear differing by up to 0.3 m/s, and 80% of the analysed regions achieving moderate or strong correlations between the predicted and in vivo velocities. CFD predicted pressures were generally well matched to the Doppler-wire measurements, with some deviation in peak systolic values. Overall, this study presents a validated comprehensive workflow with extensive data for CFD simulation of TBAD.

Obstructive Sleep Apnoea in Stanford Type B Aortic Dissection Is Associated With Multiple Imaging Signs Related to Late Aortic Events.

Background: Obstructive sleep apnoea (OSA) is highly prevalent in patients with Stanford type B aortic dissection (TBAD). Few studies have evaluated the effects of OSA on vascular changes in TBAD patients. This study aimed to explore the effect of OSA on aortic morphological changes in TBAD patients and its relation to late aortic events (LAEs).Methods: This case-control study included 143 TBAD patients. The diameters of different parts of the aorta were measured based on computed tomography angiography (CTA). According to the apnoea-hypopnoea index (AHI), OSA was classified as mild (5 ≤ AHI ≤ 15), moderate (15 < AHI ≤ 30), or severe (AHI > 30). The false lumen (FL) status was evaluated and classified as partially thrombosed, patent, or completely thrombosed.Results: The OSA prevalence in TBAD patients was 64.3%, and image differences related to LAEs between TBAD patients with and without OSA included the maximum aortic diameter at onset (37.3 ± 3.9 vs. 40.3 ± 4.5 mm, p < 0.001), the FL diameter of the proximal descending thoracic aorta (16.0 ± 6.8 vs. 20.3 ± 4.7 mm, p < 0.001), and the proportion of the FL that was partially thrombosed (39.2 vs. 64.1%, p = 0.004). Additionally, in the multivariable analysis of patients with OSA, the risks of an aortic diameter ≥40 mm, a proximal descending aorta FL ≥ 22 mm and a partially thrombosed FL were 4.611 (95% CI: 1.796–11.838, p = 0.001), 2.544 (95% CI: 1.050–6.165, p = 0.039), and 2.565 (95% CI: 1.167–5.637, p = 0.019), respectively, after adjustment for confounding factors. Trend tests showed that the risks of an aortic diameter ≥40 mm and a partially thrombosed FL increased with increasing OSA severity.Conclusions: TBAD patients with moderate to severe OSA have aortic dilatation in different parts of the aorta. OSA is an independent risk factor for multiple imaging signs related to LAEs, suggesting that OSA is an important factor affecting the prognosis of TBAD patients.

Systemic immune-inflammation index predicted the clinical outcome in patients with type-B aortic dissection undergoing thoracic endovascular repair.

The systemic immune-inflammation index (SII) has been reported to have prognostic ability in various cardiovascular diseases; however, it has not been studied in type-B aortic dissection (TBAD). We aimed to explore the relation of SII with short-term and long-term outcomes in TBAD patients undergoing thoracic endovascular repair (TEVAR). We performed a retrospective analysis of a prospectively maintained database from 2010 to 2017. The patients were divided into two groups (high SII and low SII) as per the optimal cut-off value determined using the receiver operating characteristic curve. Multivariate logistic and Cox regression analyses were performed to analyse the relationship between the SII and the short-term and long-term outcomes. A total of 805TBAD patients who underwent TEVAR were enrolled. Twenty-six (3.2%) patients died during hospitalisation. At the end of a median follow-up duration of 48.80mon, 70 (9.8%) patients had died. The patients were divided into the high-SII group [n=333 (41.4%%)] and the low-SII group [n=472 (58.6%)] as per the optimal cut-off value of 1,062. Multivariable logistic analyses showed that a high-SII score was independently associated with major adverse cardiovascular events (MACEs) in-hospital (odd ratio [OR], 1.67; 95% confidence interval [CI], 1.13-2.47; p=.01). In addition, multivariable Cox analyses showed that a high-SII score could be an independent indicator for follow-up adverse events (hazard ratio [HR], 1.70; 95% CI, 1.14-2.56, p=.01). Systemic immune-inflammation index is associated with both in-hospital and long-term outcomes in patients with TBAD undergoing TEVAR. Therefore, SII may serve as valuable tool for risk stratification before intervention.

Racial Disparities in Presentation and Short-term Outcome in Patients With Acute Type B Aortic Dissection

Racial Disparities in Presentation and Short-term Outcome in Patients With Acute Type B Aortic Dissection

Dexmedetomidine reduces acute kidney injury after endovascular aortic repair of Stanford type B aortic dissection: A randomized, double-blind, placebo-controlled pilot study

Study objectiveTo determine the effect of dexmedetomidine on acute kidney injury (AKI) following endovascular aortic repair (EVAR) for Stanford type B aortic dissection (TBAD). DesignRandomized, double-blind, placebo-controlled, pilot study. SettingUniversity Hospital. Patients102 TBAD patients undergoing EVAR procedures were enrolled. Patients with dissection involving aortic arch or renal artery were excluded. InterventionsPatients were randomly assigned, in a 1:1 ratio, to a dexmedetomidine group (intravenous dexmedetomidine 0.4 μg/kg/h immediately after anesthesia induction and 0.1 μg/kg/h after extubation, which was maintained until 24 h) or a normal saline control group. MeasurementsThe primary outcome was the incidence of AKI within the first two days after surgery, based on the Acute Kidney Injury Network (AKIN) criteria. The secondary outcomes included serum cystatin C and estimated glomerular filtration rate on postoperative days 1, 2, and 7, and in-hospital need for renal replacement therapy (RRT). Long-term outcomes included RRT and all-cause mortality. Main resultsNinety-eight patients completed the study (dexmedetomidine, n = 48; control, n = 50). AKIN stage 1 AKI occurred in 3/48 (6.3%) patients receiving dexmedetomidine, compared with 11/50 (22%) patients receiving normal saline (odds ratio = 0.24, 95% CI: 0.07 to 0.89, P = 0.041). This difference remained significant after adjusting for baseline covariates (adjusted odds ratio = 0.21, 95% CI: 0.05 to 0.84; P = 0.028). Dexmedetomidine led to a lower serum cystatin C on postoperative day 1 (median [IQR] mg/L: 1.31 [1.02–1.72] vs. 1.58 [1.28–1.96]). There were no between-group differences in other secondary or long-term outcomes. During the follow-up (median = 28.4 months), 1 patient in the dexmedetomidine group and 3 patients in the control group required RRT. ConclusionsDexmedetomidine reduced the incidence of AKI in TBAD patients after EVAR procedures. The long-term benefits of dexmedetomidine in this patient population warrant further investigation.Trial registration: ChiCTR-IPR-15006372.

Abstract P102: False Lumen Volume Is A Predictor Of Successful Thoracic Endovascular Aortic Repair

Objectives: Thoracic endovascular aortic repair (TEVAR) is becoming the treatment modality of choice for type B aortic dissection (TBAD). Using CTA imaging, clinicians track dissection evolution; however, clinical imaging analysis is limited to linearized measurements of maximum diameter that poorly predict post-operative outcomes. Achieving post-operative thrombosis of the false lumen is a desired characteristic that is thought to prevent aneurysmal degeneration, complication, and reintervention. We hypothesize that decrease in false lumen volume can be used to accurately predict successful TEVAR, as defined by lack of reintervention. Methods: We studied 20 TBAD patients that underwent TEVAR, 10 with desired outcomes, defined by the absence of post-operative reintervention, and 10 with failed outcomes, defined by the presence of reintervention. Utilizing CTA imaging, we performed pre- and post-operative segmentations of the false lumen for each patient. We calculated the volume of the false lumen of each scan. We performed two-sample t-tests on the null hypothesis that false lumen volume does not change post-TEVAR. We also tested the null hypothesis that patients with desired outcomes and poor outcomes have equal false lumen volumes. Results: We found a statistically significant difference in the pre-operative false lumen volume of patients with desired outcomes post-TEVAR versus patients with failed outcomes (p=0.014). However, we found no statistically significant change in false lumen volume of patients with successful or failed TEVAR. Conclusions: Pre-operative false lumen volume distinguishes desired versus failed post-TEVAR outcomes. While our initial hypothesis was not proven, our results identify that pre-operative false lumen volume is a viable predictor of TEVAR success. The clinical implication of our finding is that patients with a large false lumen volume may not be ideal candidates for an endovascular approach to TBAD repair.

Analysis of clinical characteristics and prognostic risk factors in patients with Stanford type B aortic dissection complicated with hypertension

To investigate the clinical characteristics as well as short-term and long-term prognostic factors of patients with Stanford type B aortic dissection (TBAD) with hypertension. Patients with TBAD who received thoracic endovascular aortic repair (TEVAR) admitted to Xiangyang Central Hospital from January 2014 to December 2018 were enrolled. The baseline data of patients admitted to the hospital were collected through the case management system, including gender, age, underlying diseases (hypertension, diabetes, coronary heart disease), smoking history, drinking history, duration of pain, vital signs at admission [heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP)], laboratory results [white blood cell count (WBC), platelet count (PLT), neutrophil/lymphocyte ratio (NLR), serum creatinine (SCr), C-reactive protein (CRP), D-dimer, ascending aorta diameter], etc. The clinical characteristics of TBAD patients with hypertension were analyzed. Logistic regression model and Cox proportional risk model were used to analyze the impact of hypertension on the short-term and long-term all-cause deaths after TEVAR in TBAD patients. Among 227 TBAD patients, 160 cases (70.5%) were complicated with hypertension, while 67 cases (29.5%) were not. The average age, the proportion of diabetes and coronary heart disease, and the level of SBP, DBP and SCr at admission of TBAD patients with hypertension were higher than those of TBAD without hypertension [age (years old): 53.1±11.9 vs. 42.8±14.1, combined with diabetes: 8.8% vs. 1.5%, combined with coronary heart disease: 6.3% vs. 0%, SBP (mmHg, 1 mmHg = 0.133 kPa): 147.9±18.1 vs. 136.9±15.2, DBP (mmHg): 93.9±11.9 vs. 89.1±13.8, SCr (μmol/L): 97.8±25.4 vs. 89.8±23.6, all P < 0.05]. The short-term mortality of TBAD with hypertension group was significantly higher than that of TBAD without hypertension group [6.3% (10/160) vs. 0% (0/67), χ2 = 4.386, P = 0.036]. 227 patients with TBAD were followed up for 3-66 months, with a median follow-up time of 25 months. There was no significant difference in long-term mortality between TBAD patients with and without hypertensive during discharge follow-up [13.1% (21/160) vs. 9.0% (6/67), χ2 = 0.784, P = 0.376]. Further multivariate Logistic regression analysis and Cox regression analysis did not indicate that hypertension was an independent risk factor for short-term and long-term death in TBAD patients [odds ratio (OR) and 95% confidence interval (95%CI) were 13.477 (0.541-330.215), 1.012 (0.990-1.035), both P > 0.05]. Age and HR were independent risk factors for the short-term mortality of TBAD patients [OR and 95%CI were 15.287 (1.051-226.415), 0.026 (0.002-0.840), both P < 0.05]. Age, PLT and D-dimer were independent risk factors for the long-term mortality of TBAD patients [OR and 95%CI were 1.808 (1.205-2.711), 0.555 (0.333-0.924), 1.482 (1.035-2.122), respectively, all P < 0.05]. The TBAD patients with hypertension have older age, high rates of diabetes or coronary heart disease. However, hypertension is not an independent risk factor for short-term and long-term mortality in TBAD patients.

Incidence, Predictors and Outcomes of Delirium in Complicated Type B Aortic Dissection Patients After Thoracic Endovascular Aortic Repair.

PurposeThe present study aimed to investigate the incidence and predictors of post-operative delirium (POD) in patients with complicated type B aortic dissection (TBAD) undergoing TEVAR with/without concomitant procedures and to assess the association of POD with early and follow-up outcomes.MethodsA retrospective single-center cross-sectional analysis was conducted using a prospectively maintained database from 2010 to 2017. Outcomes were postoperative clinical outcomes, early and follow-up survival.ResultsA total of 517 complicated TBAD patients were enrolled. POD was observed in 13.3% (69/517) patients and was associated with increased hospital length of stay (LOS) and hospital costs (P< 0.001 for both). Besides, POD was found to be an independent risk factor for prolonged ICU stay (odds ratio [OR] 4.39, 95% confidence interval [CI] 2.40–8.01, P< 0.001) and early death (OR 4.42, 95% CI 1.26–15.54, P= 0.020). Predictors of POD were hybrid procedure (OR 2.17, 95% CI 1.20–3.92, P= 0.010), the use of benzodiazepine (OR 1.86, 95% CI 1.07–3.23, P= 0.027) or quinolone (OR 2.35, 95% CI 1.26–4.38, P= 0.007), creatinine >2 mg/dL (OR 3.25, 95% CI 1.57–6.72, P= 0.001) and preoperative blood transfusion (OR 3.31, 95% CI 1.76–6.21, P< 0.001). After a median follow-up of 73.6 months, POD remained as an independent indicator for follow-up mortality (hazard ratio [HR] 2.40, 95% CI 1.31–4.38, P= 0.005) after adjusting potential confounders.ConclusionPOD after TEVAR has an incidence of around 13% and could profoundly increase the in-hospital LOS, hospital costs, as well as the early and follow-up mortality. A series of risk factors, including hybrid procedure, the use of benzodiazepine or quinolone, creatinine >2 mg/dL and preoperative blood transfusion, were identified as independent risk factors for POD. Effective risk-stratification and patient-tailored management strategy should be developed to reduce the incidence of POD.

TEVAR for complicated anduncomplicated type B aortic dissection-Systematic review and meta-analysis.

Type B aortic dissection (TBAD), is defined as a dissection involving the aorta distal to left subclavian artery with the ascending aorta and the aortic arch not affected. TBAD is classified due to the time frame and presence of complications. Complicated TBAD (co-TBAD) patients have a greater mortality rate than uncomplicated TBAD (un-TBAD) and thoracic endovascular aortic repair (TEVAR) is considered the gold-standard intervention for these clinical challenges. We undertook a systematic review of the literature regarding TEVAR intervention in co-TBAD and un-TBAD. A comprehensive search was undertaken across four major databases and was evaluated and assessed until June 2020. A total of 16,104 patients were included in the study (7772 patients co-TBAD and 8352 un-TBAD). A significantly higher proportion of comorbidities were seen in co-TBAD patients compared with un-TBAD. Acute dissection was more frequent in the co-TBAD group (73.55% vs. 66.91%), while chronic dissection was more common in un-TBAD patients (33.8% vs. 70.73%). Postprocedure stroke was higher in co-TBAD (5.85% vs. 3.92%; p < .01), while postprocedural renal failure was higher in un-TBAD patients (7.23 vs. 11.38%;p < .01). No difference was observed in in-hospital mortality however the 30 days mortality was higher in the co-TBAD group. One-year survival was higher in the uncomplicated group but this difference was not observed in the 5-year survival. In our analysis we can appreciate that despite significantly higher comorbidities in the co-TBAD cohort, there was no difference in in-hospital mortality between the two groups and the 5-year survival did not have any difference.

Predicting reintervention after thoracic endovascular aortic repair of Stanford type B aortic dissection using machine learning.

To construct models for predicting reintervention after thoracic endovascular aortic repair (TEVAR) of Stanford type B aortic dissection (TBAD). A total of 192 TBAD patients who underwent TEVAR were included; 68 (35.4%) had indications for reintervention. Clinical characteristics, aorta characteristics on pre- and postoperative computed tomography angiography, and aorta characteristics on immediate postoperative aortic digital subtraction angiography were collected. The least absolute shrinkage and selection operator (LASSO) regression was applied to identify the risk factors for reintervention. Eight classifiers were used for modeling. The models were trained on 100 train-validation random splits with a ratio of 2:1. The performance was evaluated by the receiver operating characteristic curve. Seven predictors of reintervention were identified, including maximum false lumen diameter, aortic diameter measured at the level of approximately 15 mm distal to the left subclavian artery, aortic diameter measured at the level of the diaphragm, false lumen diameter measured at the level of the celiac artery, number of bare-metal and covered stents, number of bare-metal stents, and residual perfusion of the false lumen. Logistic regression (LR) yielded the highest performance, with an area under the curve of 0.802. A nomogram built for clinical use showed good calibration. The cutoff value for dividing patients into low- and high-risk subgroups was 0.413. Kaplan-Meier curves showed that the overall survival of high-risk patients was significantly shorter than that of low-risk patients (both p < 0.05). Our nomogram could predict the reintervention after TEVAR in patients with TBAD, which may facilitate patient selection and surveillance strategies. • Seven risk factors of reintervention after TEVAR of TBAD were identified for modeling. • Logistic regression performed best in predicting reintervention with an AUC of 0.802. • Patients with a high risk of reintervention had shorter OS than those with a low risk.

Analysis of aortic wall stress and morphology in patients with type B aortic dissection

Risk assessment is critical in preventing aortic dissection (AD). This study aims to evaluate the wall stress (WS) distribution, especially at the locations of proximal tears in patient-specific type-B aortic dissection (TBAD) to explore the pathogenesis of dissection. In addition, the shape of the aortas were assessed and associated with TBAD risk. In this paper, 30 three-dimensional models were reconstructed based on patient-specific CT angiography images, and finite element analysis (FEA) was used to analyze the admission blood pressure. In addition, the anatomic variables including the head vessel angles, the aorta diameters, curvatures and torturosity ware measured. Tears occurred at either local high WS or low WS region, and these acute TBAD patients can be classified into three groups based on the location of initial intimal tears. In addition, the WS values at tear sites of each group showed significant difference (P＜0.001). Moreover, the angles of the left subclavian and brachiocephalic arteries were statistical different among three groups. Increased wall stress or decreased wall strength both contribute to the pathogenesis of aortic dissections. In addition, abnormal head vessel angles may be monitored as an important risk factor for aortic dissection, and its specific features may further help to determine the potential tear location.