Importance of refractory pain and hypertension in acute type B aortic dissection: insights from the International Registry of Acute Aortic Dissection (IRAD).

BACKGROUND: In patients with acute type B aortic dissection, presence of recurrent or refractory pain and/or refractory hypertension on medical therapy is sometimes used as an indication for invasive treatment. The International Registry of Acute Aortic Dissection (IRAD) was used to investigate the impact of refractory pain and/or refractory hypertension on the outcomes of acute type B aortic dissection. METHODS AND RESULTS: Three hundred sixty-five patients affected by uncomplicated acute type B aortic dissection, enrolled in IRAD from 1996 to 2004, were categorized according to risk profile into 2 groups. Patients with recurrent and/or refractory pain or refractory hypertension (group I; n=69) and patients without clinical complications at presentation (group II; n=296) were compared. "High-risk" patients with classic complications were excluded from this analysis. The overall in-hospital mortality was 6.5% and was increased in group I compared with group II (17.4% versus 4.0%; P=0.0003). The in-hospital mortality after medical management was significantly increased in group I compared with group II (35.6% versus 1.5%; P=0.0003). Mortality rates after surgical (20% versus 28%; P=0.74) or endovascular management (3.7% versus 9.1%; P=0.50) did not differ significantly between group I and group II, respectively. A multivariable logistic regression model confirmed that recurrent and/or refractory pain or refractory hypertension was a predictor of in-hospital mortality (odds ratio, 3.31; 95% confidence interval, 1.04 to 10.45; P=0.041). CONCLUSIONS: Recurrent pain and refractory hypertension appeared as clinical signs associated with increased in-hospital mortality, particularly when managed medically. These observations suggest that aortic intervention, such as via an endovascular approach, may be indicated in this intermediate-risk group.

Role of age in acute type A aortic dissection outcome: report from the International Registry of Acute Aortic Dissection (IRAD).

OBJECTIVE: The increasing life expectancy of the population will likely be accompanied by a rise in the incidence of acute type A aortic dissection. However, because of an increased risk of cardiac surgery in an elderly population, it is important to define when, if at all, the risks of aortic repair outweigh the risk of death from unoperated type A aortic dissection. METHODS: We analyzed 936 patients with type A aortic dissection enrolled in the International Registry of Acute Aortic Dissection from 1996 to 2004. Patients with type A aortic dissection were categorized according to patient age by decade and by surgical versus medical management, and outcomes of both management types were investigated in the different age groups. RESULTS: The rate of surgical aortic repair decreased progressively with age, whereas surgical mortality significantly increased with age. Age 70 years or more was an independent predictor for mortality (38.2% vs 26.0%; P < .0001, odds ratio 1.73). The in-hospital mortality rate was significantly lower after surgical management compared with medical management until the age of 80 years. For patients aged 80 to 90 years, the in-hospital mortality appeared to be lower after surgical management (37.9% vs 55.2%; P = .188); however, this failed to reach clinical significance owing to the limited patient number in this age group. CONCLUSIONS: Although the surgical mortality significantly increased with increased age, surgical management was still associated with significantly lower in-hospital mortality rates compared with medical management until the age of 80 years. Surgery may decrease the in-hospital mortality rate for octogenarians with type A aortic dissection and might be considered in all patients with type A aortic dissection regardless of age.

Acute abdominal aortic dissection: insight from the International Registry of Acute Aortic Dissection (IRAD).

BACKGROUND: Isolated acute dissection of the abdominal aorta is an unusual event that may present with several different clinical scenarios. Because its incidence is low, the natural history is unknown. We report data from the International Registry of Acute Aortic Dissection (IRAD), the largest group of patients treated for acute aortic dissections. The aim of this study was to identify clinical characteristics, therapeutic approaches, risk factors for mortality, in-hospital outcome, and long-term results of this cohort, thus clarifying its natural history. METHODS: A comprehensive analysis of 290 clinical variables on 18 patients affected by isolated acute abdominal aortic dissection (IAAAD) was performed. Among 1417 patients enrolled in the IRAD from 1996 to 2003, 532 (37.5%) had an acute type B dissection, of which 18 (1.3%) had an IAAAD. Theor mean age was 67.7 +/- 13.3 years, with a male predominance (n = 12, 67%). Aortic aneurysms pre-existed in 5 patients (28%). IAAAD was iatrogenic in 2 cases (11%). RESULTS: Compared with patients with type B aortic dissections, abdominal pain, mesenteric ischemia or infarction, limb ischemia, and hypotension as initial clinical signs were significantly more frequent in patients with IAAAD, whereas chest pain was more typical in patients with type B dissections. No neurologic symptoms, such as ischemic spinal cord damage or ischemic peripheral neuropathy, occurred in the IAAAD cohort. The 18 IAAAD patients were medically, surgically, or percutaneously managed in 12 (66.6%), five (27.8%), and one (5.6%) cases, respectively. The overall in-hospital mortality rate was 5.6% (n = 1). The patient who died was medically managed. No deaths were reported among patients who underwent surgery or had an endovascular procedure, irrespective of their preoperative status. A mean follow-up of 5 years (range, 1 month to 9 years) was completed for 71% (12 of 17) of the patients. Four patients (33.3%) died during the 9-year follow-up period. Overall survival was 93.3% +/- 12.6% at 1 year and 73.3% +/- 27.2% at 5 years. All patients who died during the follow-up period had in-hospital medical management (P = .04). CONCLUSIONS: IAAAD is a condition that may present differently compared with classic type B aortic dissections. IAAAD patients treated with surgical or endovascular procedures had a lower unadjusted in-hospital and long-term mortality rate compared with medically managed patients. On the basis of the present natural history report, continued surveillance appears mandatory. To improve the life expectancy of patients with IAAAD, aggressive surgical or endovascular management seems justified.