Black patients have a higher burden of comorbidities but a lower risk of 30-day and 1-year mortality after thoracic endovascular aortic repair.

BACKGROUND: Racial disparities in open thoracic aortic aneurysm repair have been well-documented, with Black patients reported to suffer from poor outcomes compared with their White counterparts. It is unclear whether these disparities extend to the less invasive thoracic endovascular aortic repair (TEVAR). This study aims to examine the clinical characteristics, perioperative outcomes, and 1-year survival of Black vs White patients undergoing TEVAR in a national vascular surgery database. METHODS: The Vascular Quality Initiative database was retrospectively queried to identify all patients who underwent TEVAR between January 2011 and December 2019. The primary outcomes were 30-day mortality and 1-year survival after TEVAR. Secondary outcomes included various types of major postoperative complications. Multivariable logistic regression analyses were performed to identify predictors of 30-day mortality and perioperative complications. Multivariable Cox regression analysis was used to determine the predictors of 1-year survival. RESULTS: A total of 2669 patients with TEVAR were identified in the Vascular Quality Initiative, of whom 648 were Black patients (24.3%). Compared with White patients, Black patients were younger and had a higher burden of comorbidities, including hypertension, diabetes, congestive heart failure, dialysis dependence, and anemia. Black patients were more likely to be symptomatic, present with aortic dissection, and undergo urgent or emergent repair. There was no statistically significant difference in 30-day mortality between Black and White patients (3.4% vs 4.9%; P = .1). After adjustment for demographics, comorbidities, and operative factors, Black patients were independently associated with a 56% decrease in 30-day mortality risk compared with their White counterparts (odds ratio, 0.44; 95% confidence interval [CI], 0.22-0.85; P = .01) and not associated with an increased risk of perioperative complications (odds ratio, 0.90; 95% CI, 0.68-1.17; P = .42). Black patients also had a significantly better 1-year overall survival (log-rank, P = .024) and were associated with a significantly decreased 1-year mortality (hazard ratio, 0.65; 95% CI, 0.47-0.91; P = .01) after adjusting for multiple clinical factors. CONCLUSIONS: Although Black patients carried a higher burden of comorbidities, the racial disparities in perioperative outcomes and 1-year survival do not persist in TEVAR.

The interaction effects between TLR4 and MMP9 gene polymorphisms contribute to aortic aneurysm risk in a Chinese Han population.

BACKGROUND: A cross-talk between Toll-like receptor 4 (TLR4) and matrix metalloproteinase 9 (MMP9) plays a vital role in aortic pathophysiology. The objective of this study was to evaluate the interactions between TLR4 and MMP9 polymorphisms in the risk of aortic aneurysm (AA) and its subtypes. METHODS: KASP method was used to detect polymorphisms of TLR4 (rs11536889 and rs1927914) and MMP9 (rs17576) in 472 AA patients and 498 controls. According to location and size, AA patients were further classified into abdominal AA (AAA), thoracic AA (TAA), and large AA (>5.0 cm), small AA(≤5.0 cm), respectively. RESULTS: The significant interaction effect of TLR4rs1927914 with MMP9rs17576 polymorphisms was observed for the risk of TAA (Pinteraction = 0.038, OR = 6.186) and large AA (Pinteraction = 0.044, OR = 5.892). There were epistatic effects between TLR4rs1927914 and MMP9rs17576 polymorphisms on the risk of overall AA, AAA, TAA and large AA when they were present together. Moreover, the cumulative effects of the pairwise interaction TLR4rs1927914-MMP9rs17576 were associated with an increased risk of overall AA (Ptrend = 0.032) and AAA (Ptrend = 0.031). CONCLUSIONS: The novel interaction between TLR4rs1927914 and MMP9rs17576 polymorphisms could increase the risk of AA disease or its subtypes by exerting epistatic and cumulative effects.

Common Femoral Artery Caliber Changes after Percutaneous versus Surgical Access in Endovascular Aneurysm Repair in the Asian Population.

BACKGROUND: Western studies showed vascular caliber changes post-endovascular aneurysm repair (EVAR). This study aims to evaluate for postoperative changes of the common femoral artery inner diameter (CFA ID) in the Asian population. METHODS: From January 2011 to June 2016, 202 patients who underwent EVAR were reviewed. CFA IDs were evaluated at 3 fixed levels on computed tomography (CT) aortograms. Preoperative and postoperative measurements were compared. Per-groin analysis was carried out after division into percutaneous access endovascular aneurysm repair (PEVAR) and surgical access endovascular aneurysm repair (SEVAR) groups. Independent sample t-test compared for differences in overall CFA ID changes between PEVAR and SEVAR groups. Paired sample t-test evaluated CFA ID changes in each group. P value < 0.05 was considered significant. RESULTS: One hundred and twenty patients were included, with 200 groins subsequently analyzed. The PEVAR and SEVAR groups have no significant demographic differences, except in sheath size and duration of CT aortogram follow-up. No significant differences in overall CFA ID changes comparing PEVAR and SEVAR groups (-0.12 ± 1.05 mm, -0.10 ± 0.81 mm, P = 0.36). No significant overall CFA ID changes in both PEVAR (7.92 ± 1.23 mm, 7.80 ± 1.38 mm, P = 0.34) and SEVAR groups (7.47 ± 1.44 mm, 7.36 ± 1.64 mm, P = 0.15). CONCLUSIONS: No significant differences in CFA caliber changes comparing PEVAR and SEVAR. No significant CFA caliber changes in either group.

Association of TNF-α gene variations with thoracic aortic dissection risk in a Chinese Han population.

BACKGROUND: Chronic inflammation may be involved in pathogenesis of thoracic aortic dissection (TAD). Tumor necrosis factor-alpha (TNF-α) is a proinflammatory cytokine that plays an important role in pathological TAD progression. In this study, we determined wether genetic variants of TNF-α were associated with TAD. METHODS: Frequency distributions of TNF-α promoter polymorphisms (-1031C/T,-857C/T,-308G/A, and -238G/A) were determined by direct sequencing. TNF-α plasma levels were measured by enzyme-linked immunosorbent assay. Plasma levels of TNF-α mRNA in peripheral-blood mononuclear cells were analyzed by real-time quantitative polymerase chain reaction amplification. RESULTS: We found the TNF-α promoter -857C/T polymorphism is associated with disease progression susceptibility in TAD patients. The CC homozygote of TAD patients had a significantly higher risk of TAD than did T allele carriers (P< 0.05). Plasma TNF-α concentrations were also significantly higher in TAD patients than control subjects (P<0.05), and CC genotype carriers showed increased TNF-α levels compared with T allele carriers (P<0.05). Moreover, peripheral-blood mononuclear cells carrying the CC genotype showed increased TNF-α mRNA levels compared with cells carrying the T allele. CONCLUSIONS: The -857C/T polymorphism of TNF-α promoter plays a role in the genetic variation underlying susceptibility of individuals to TAD progression. The CC genotype is associated with increased TNF-α expression in TAD patients, and may be an independent predictive factor for TAD.

Advanced complicated diabetes mellitus is associated with a reduced risk of thoracic and abdominal aortic aneurysm rupture: a population-based cohort study.

BACKGROUND: Studies have associated diabetes mellitus (DM) with the reduced risk of abdominal aortic aneurysm and thoracic aortic aneurysm and dissection. We used the national insurance data of Taiwan to examine these correlations for an Asian population. The association was also evaluated by DM severity. METHODS: We identified 160,391 patients with type 2 DM diagnosed from 1998 to 2008 and 646,710 comparison subjects without DM, frequency matched by diagnosis date, sex and age (mainly the elderly). The DM severity was partitioned into advanced and uncomplicated status according to DM-related comorbidities. RESULTS: By the end of 2010, the overall pooled incidence rate of thoracic aortic aneurysm and abdominal aortic aneurysm was 15% lower in the type 2 DM cohort than in non-DM cohort, with an adjusted hazard ratio of 0.64 [95% confidence interval (CI) 0.56-0.74] in the multivariable Cox model. Patients with advanced type 2 DM were significantly associated with reduced thoracic aortic aneurysm rupture and abdominal aortic aneurysm without rupture, with adjusted hazard ratios of 0.50 (95% CI 0.35-0.71) and 0.53 (95% CI 0.40-0.69), respectively. Uncomplicated type 2 DM was also associated with reduced abdominal aortic aneurysm without rapture (aHR = 0.58, 95% CI 0.45-0.74). CONCLUSIONS: Our results demonstrate that patients with diabetes in this Asian population have reduced prevalence of thoracic and abdominal aortic aneurysms. The observed paradoxical inverse relationship between severity of DM and aortic aneurysms is clear. Further research is required to investigate the underlying mechanisms for the reduced risk of aortic aneurysms associated with diabetes.

rs10263935 and rs6045676 identified by genome-wide association study were associated with aortic dissection in a Chinese population.

Aortic dissection (AD) is a disease characterized by a tear in the aortic intimal layer and separation of the arterial wall. Some risk factors, such as hypertension and Marfan syndrome, are well known in AD, but the role of genetic factor is largely unknown. In this study, we investigated the relation between two single nucleotide polymorphisms (SNPs) identified by genome-wide association study and AD. Approximately 177 patients diagnosed with AD through clinical evaluation and imaging techniques and 183 age- and sex-matched control subjects who were suffering from chest pain but without AD were included in the study. Genotyping of rs10263935 and rs6045676 was performed in both patients and control subjects using the TaqMan(®) method [Life Technologies (AB & Invitrogen), Carlsbad, CA]. The frequency of the AA and AG genotype in rs10263935 was significantly higher in the AD patients (0.085 and 0.435, respectively) than in the control subjects (0.033 and 0.355, respectively). The rs10263935 A allele frequency in the AD patients was higher than that in the control subjects [0.302 vs 0.210, odds ratio (OR) = 1.62, 95% confidence interval (CI): 1.26-2.28, P = 0.005]. Similarly, the frequency of the GG genotype in rs6045676 was significantly higher in the AD patients than in the control subjects (0.107 vs 0.038, P = 0.015). The rs6045676 G allele frequency in the AD patients was higher than that in the control subjects (0.282 vs 0.191, OR = 1.67, 95% CI: 1.18-2.50, P = 0.004). After adjustment of the confounding factors, such as smoking, sex, and age, the differences remain significant in several models (rs10263935: GG vs AA: OR = 3.13, 95% CI: 1.15-8.33, P = 0.025; GG vs AG: OR = 1.57, 95% CI: 1.01-2.44, P = 0.045; rs6045676: GG vs CC: OR = 3.30, 95% CI: 1.32-8.25, P = 0.011). rs10263935 on chromosome 7 and rs6045676 on chromosome 20 are associated with AD. Further studies are warranted to elucidate the functional role of these two variants.

Computed tomography-based study exploring the feasibility of endovascular treatment of type A aortic dissection in the Chinese population.

PURPOSE: To characterize type A aortic dissection (TAAD) in the Chinese population using high-resolution computed tomography (CT) and explore potential candidacy for endovascular repair of TAAD. METHODS: The imaging studies and medical records of all 302 patients presenting with TAAD at two Chinese hospitals from 2010 to 2013 were reviewed. Of these, 221 patients were excluded because of missing/inadequate preoperative CT scans. The remaining 91 patients (64 men; mean age 51.1±7.5 years) had CT data adequate to assess anatomical suitability for endovascular treatment. Entry tears were identified using multiplanar reconstructions, while morphological measurements were based on a centerline of flow (CLF) technique. Suitability for endovascular treatment was based on a proximal landing zone ≥20 mm long, a true lumen aortic diameter ≤38 mm, and a total aortic diameter ≤46 mm; no coronary bypass grafts originating from the ascending aorta; no malfunctioning aortic valve; and good cerebral and cardiac perfusion. RESULTS: In the 91 patients, the precise location of the primary proximal entry tear could be identified in only 34 (37.4%) patients; in these patients, the identifiable intimal tears were located 36.4±41.0 mm distal to the closest coronary artery. The CLF was successfully generated in the CT scans of all patients; the mean lumen and total aortic lumen diameters at the entry tear level were 37.6±6.3 and 44.3±13.3 mm, respectively. Based on the CT measurements, stent-graft repair would have been anatomically feasible in 35 (38.5%) patients. No proximal landing zone (n=23), large aortic diameter (n=15), abnormal aortic valve (n=10), previous coronary bypass graft surgery (n=5), and poor cerebral and cardiac perfusion (n=3) were obstacles that affected the suitability for this treatment. CONCLUSION: Based on high-resolution CT scans, our pilot study suggested that 38% of Chinese patients with TAAD could potentially be treated by stent-grafting based on the anatomical characteristics of the proximal dissection.

Association of the polymorphisms of MMP-9 and TIMP-3 genes with thoracic aortic dissection in Chinese Han population.

AIM: Thoracic aortic dissection (TAD) is the most common life-threatening disorder, and a shifted balance of matrix metalloproteinases (MMPs) and tissue inhibitors of metalloproteinases (TIMPs) is involved in TAD pathogenesis. The aim of this study was to evaluate the association of 4 single-nucleotide polymorphisms (SNPs) in MMP-9 and TIMP-3 genes with TAD risk in Chinese Han population. METHODS: A total of 206 Chinese patients with TAD and 180 controls were included in this study. Four SNPs (rs3918249, rs2274756, rs9609643 and rs8136803) were genotyped using high-throughput MALDI-TOF mass spectrometry. Allele and genotype association analyses were conducted using PLINK. RESULTS: All the 4 SNPs resulted in Hardy-Weinberg equilibrium in patients and controls. The G allele frequency for the MMP-9 SNP rs2274756 was significantly higher in female TAD patients than in female controls (P=0.0099). Moreover, after adjusting for traditional cardiovascular risk factors (sex, age, hypertension, dyslipidemia, diabetes and smoking habit), the rs2274756 polymorphism (odds ratio: 0.30; 95% confidence interval: 0.11 to 0.79, P=0.015) resulted in an independent susceptibility factor for TAD in females. No associations were found between the other SNPs and TAD. CONCLUSION: The results provide strong evidence for an association between MMP-9 SNP rs2274756 and female TAD risk in Chinese Han population.

Association of race and socioeconomic status with the use of endovascular repair to treat thoracic aortic diseases.

OBJECTIVE: Descending thoracic aortic diseases may be treated with either open thoracic aortic repair or thoracic endovascular aortic repair (TEVAR). Previous studies have demonstrated that race and socioeconomic status (SES) affect access to care and treatment allocation in vascular surgery. We hypothesized that racial minorities and lower SES patients have decreased propensity to have their thoracic aortic disease treated with TEVAR. METHODS: Weighted discharge records for patients who underwent either open thoracic aortic repair or TEVAR between 2005 and 2008 were evaluated using the Nationwide Inpatient Sample. Patient records were stratified by therapeutic intervention (open repair vs TEVAR). Differences in baseline comorbidities, race, and SES were compared. To account for the effects of comorbidities and other factors, hierarchical logistic regression modeling was used to determine the likelihood for TEVAR performance based on differences in patients' race and SES. RESULTS: A total of 60,784 thoracic repairs were analyzed, the majority (79.4%) of which were open repairs. The most common race was white (78.2%), followed by black (9.1%), Hispanic (5.7%), Asian or Pacific Islander (2.9%), and Native American (0.7%). Patients were divided into quartiles according to SES with 20.6% of patients in the lowest SES quartile, 24.3% in the second quartile, 26.4% in the third quartile, and 28.8% in the highest SES quartile. Indications for treatment were similar for both treatment groups. After adjusting for multiple patient and hospital factors, race and SES were significantly associated with treatment modality for thoracic aortic disease. Black, Hispanic, and Native American populations had increased adjusted odds ratios of TEVAR performance compared with white patients. Similarly, lower SES correlated with increased use of TEVAR. CONCLUSIONS: Contrary to our initial hypothesis, racial minorities (Black, Hispanic, and Native American) and patients with lower median household incomes have a greater association with the performance for TEVAR after accounting for patient comorbid disease, indication for treatment, payer status, and hospital volume. These results indicate that traditional racial disparities do not persist in TEVAR allocation.

Open repair of intact thoracoabdominal aortic aneurysms in the American College of Surgeons National Surgical Quality Improvement Program.

OBJECTIVE: Open surgical repair of thoracoabdominal aortic aneurysms (TAAAs) is uncommon. Mortality rates of 20% are reported in studies using national data and are 5% to 8% in single-institution studies. Clinical trials are currently evaluating branched and fenestrated endografts. The purpose of this study is to establish a benchmark for future comparisons with endovascular trials using open repair of TAAAs in the National Surgical Quality Improvement Program (NSQIP) database. METHODS: We identified all patients undergoing open elective and emergency surgical repair of intact TAAAs in NSQIP (2005 to 2010) using Current Procedural Terminology (American Medical Association, Chicago, Ill) and International Classification of Diseases, 9th Edition codes. We analyzed demographics, comorbidities, 30-day mortality, postoperative complications, and length of stay. Multivariable logistic regression was used to identify predictors of mortality. RESULTS: We identified 450 patients who underwent open surgical repair (418 elective, 32 emergent) of an intact TAAA. Mean age was 69.4 years, 60.7% were male, and 85.6% were white. Comorbidities included hypertension (87.1%), chronic obstructive pulmonary disease (27.3%), prior stroke or transient ischemic attack (16.7%), diabetes (11.6%), and peripheral vascular disease (9.6%). Thirty-day mortality was 10.0%. Pulmonary complications were the most common: failure to wean from ventilator (39.1%), pneumonia (23.1%), and reintubation (13.8%). Acute renal failure requiring dialysis occurred in 10.7% of patients. Multivariable analysis (odds ratio [95% confidence interval]) showed predictors of mortality were emergent repair (3.3 [1.03-10.83]; P = .04), age >70 years (3.5 [1.03-7.56], P = .001), preoperative dialysis (8.4 [1.90-37.29], P = .005), cardiac complication (2.9 [1.05-8.21], P = .04), and renal complications (8.4 [3.41-20.56], P < .001). CONCLUSIONS: In this study of NSQIP hospitals, the first to analyze open surgical repair of TAAAs, the 30-day mortality rate of 10.0% is similar to single-institution reports. However, morbidity and mortality after open TAAA repair remain high, confirming the need for less invasive procedures.

Effect of ethnicity and insurance type on the outcome of open thoracic aortic aneurysm repair.

OBJECTIVES: Mortality and complication rates for open thoracic aortic aneurysm repair have declined but remain high. The purpose of this study is to determine the influence of ethnicity and insurance type on procedure selection and outcome after open thoracic aneurysm repair. METHODS: Using the Nationwide Inpatient Sample database, ethnicity and insurance type were evaluated against the outcome variables of mortality and major complications associated with open thoracic aneurysm repair. The potential cofounders of age, gender, urgency of operation, and Deyo index of comorbidities were controlled. RESULTS: Between 2001 and 2005, a total of 10,557 patients were identified who underwent elective open thoracic aneurysm repair, with a significantly greater proportion of white patients (n = 8524) compared with black patients (n = 819), Hispanic patients (n = 556), and patients categorized as other (n = 658). Most patients (67%) were male. Almost half (45%) of the procedures were performed for urgent/emergent indications. Overall mortality was 10.7% (n = 1126) and the rate of spinal cord ischemia was 0.4% (n = 43). Univariate analysis revealed significant differences among race with regard to surgery type, income, hospital region, hospital bed size, and insurance type (P < 0.0001). Differences between insurance coverage were significant for gender, surgery type, income, hospital region, and race (P < 0.0001). Bivariate analysis by race revealed differences for death (P < 0.0001), pneumonia (P < 0.0001), renal complications (P = 0.011), implant complications (P < 0.0001), temporary tracheostomy (P = 0.004), transfusion (P < 0.0001), and intubation (P < 0.0001). In terms of payer status, bivariate analysis by insurance coverage revealed differences in death (P < 0.0001), central nervous system complications (P = 0.008), pneumonia (P < 0.0001), myocardial infarction (P = 0.001), infection (P < 0.0001), renal complications (P < 0.0001), malnutrition (P < 0.0001), temporary tracheostomy (P < 0.0001), spinal cord ischemia (P = 0.001), transfusion (P < 0.0001), and intubation (P < 0.0001). CONCLUSIONS: A high percentage of open thoracic procedures (45%) are performed urgently or emergently in the United States, which is associated with increased morbidity and mortality. Both ethnicity and payer status were associated with significant differences in surgical outcomes, including mortality and frequency of complications after open thoracic aortic aneurysm repair.

Racial and ethnic disparities in the treatment of unruptured thoracoabdominal aortic aneurysms in the United States.

PURPOSE: Previous studies have found increased mortality in minority patients undergoing abdominal aortic aneurysm repair. The goal of this study was to identify racial and ethnic disparities in patients undergoing thoracoabdominal aortic aneurysm repair. MATERIALS AND METHODS: We queried the Nationwide Inpatient Sample (2005-2009) using International Classification of Diseases, Ninth Revision, Clinical Modification codes for repair of unruptured thoracoabdominal aneurysms. The primary outcome was death. Secondary outcomes included postoperative complications. We performed multivariate analysis adjusting for age, gender, race, comorbidities (Charlson index), insurance type, and surgeon and hospital operative volumes and characteristics. RESULTS: Overall, 1541 white, 207 black, and 117 Hispanic patients underwent thoracoabdominal aortic aneurysm repair. White patients tended to be older (P = 0.003), whereas black patients had a higher incidence of diabetes mellitus (P = 0.04). Black and Hispanic patients were less likely to have an elective admission (P < 0.001) and more likely to have repair performed at a hospital with a lower average annual surgical volume (P = 0.04). Postoperative complications were similar among the groups (P = 0.31). On multivariate analysis, increased mortality was independently associated with Hispanic ethnicity (relative ratio [RR], 2.57; 95% confidence interval [CI], 1.25-5.25; P = 0.01), cerebrovascular disease (RR, 1.88; 95% CI, 1.10-3.23; P = 0.02), and age (RR, 1.04; 95% CI, 1.01-1.07; P = 0.004). CONCLUSIONS: Hispanic ethnicity is independently associated with increased mortality after repair of unruptured thoracoabdominal aneurysms. This finding was independent of preoperative comorbidities, postoperative complications, and surgeon and hospital operative volumes. Further studies are necessary to determine whether this mortality difference persists after the index hospitalization.

Exon 47 skipping of fibrillin-1 leads preferentially to cardiovascular defects in patients with thoracic aortic aneurysms and dissections.

Excessive activation of the transforming growth factor beta signaling pathway and disorganized cellular skeleton caused by genetic mutations are known to be responsible for the inherited thoracic aortic aneurysms and dissections (TAAD), a life-threatening vascular disease. To investigate the genotype-phenotype correlation, we screened genetic mutations of fibrillin-1 (FBN1), transforming growth factor-ß receptor-1 (TGFBR1) and transforming growth factor-ß receptor-2 (TGFBR2) for TAAD in 7 affected families and 22 sporadic patients. Of 19 potential mutations identified in FBN1, 11 appeared novel while the others were recurrent. Two mutations were detected in TGFBR2. Eight patients carried no mutation in either of these genes. Characterization of FBN1 c.5917+6T>C in transfected HEK293 cells demonstrated that it caused skipping of exon 47, leading to the loss of the 33th calcium binding epidermal growth factor-like domain associated with Marfan syndrome. Compared with exon 46, skipping of 47 did not cause patients ectopia lentis in all carriers. To correlate genotypes with phenotypes in different human ancestries, we reviewed the published mutational studies on FBN1 and found that the probability of cardiovascular defects were significantly increased in Chinese patients with premature termination codon or splicing mutations than those with missense mutations (91.7 % vs 54.2 %, P = 0.0307) or with noncysteine-involved point mutations than those with cysteine-involved mutations (88.9 % vs 33.3 %, P = 0.0131). Thus, we conclude that exon 47 skipping of FBN1 leads preferentially to cardiovascular defects and human ancestries influence genotype-phenotype correlation in TAAD.

Thoracic endovascular aneurysm repair, race, and volume in thoracic aneurysm repair.

BACKGROUND: Volume-based disparities in surgical care are often associated with poorer results in African American patients. We examined the effect of treatment patterns and outcomes, by race, for isolated thoracic aortic aneurysm (TAA). METHODS: Using Medicare claims (1999-2007), we studied all patients undergoing repair of TAAs, via open surgery or thoracic endovascular aneurysm repair (TEVAR). We studied 30-day mortality and complications by race, procedure type, and hospital volume. RESULTS: We studied 12,573 patients who underwent open TAA repair (4% of whom were black) and 2732 patients who underwent TEVAR (8% of whom were black). In open repair, black patients had higher 30-day mortality than white patients (18% vs 10%; P<.001), while mortality rates were similar with TEVAR (8% black vs 9% white; P=.56). For open repair, black patients were more likely to undergo surgery at low-volume hospitals, where overall operative mortality was highest (14% at very low-volume hospitals, 7% at very high-volume hospitals; P<.001). However, for TEVAR, black patients were not more likely to undergo repair at low-volume hospitals, and mortality differences were not evident across volume strata (9% at very low-volume hospitals, 7% at very high-volume hospitals; P=.328). Multivariable analyses adjusting for age, sex, race, comorbidity, and volume confirmed that increased perioperative mortality was associated with black race for open surgery (OR, 2.0, 95% CI, 1.5-2.5; P<.001) but not TEVAR (OR, 0.9, 95% CI, 0.6-1.5; P=.721). CONCLUSIONS: While racial disparities in surgical care have a significant effect on mortality with open thoracoabdominal aortic aneurysm repair, black patients undergoing TEVAR obtain similar outcomes as white patients. New technology can limit the effect of racial disparities in surgical care.

Pattern of aortic aneurysms in an African country.

OBJECTIVE: We sought to describe the regional, age, and sex distribution; diagnosis; treatment; and outcome of aortic aneurysms in a Kenyan population. METHODS: This was a retrospective study at Kenyatta National Hospital, Kenya. Records of black African patients whose final diagnosis was aortic aneurysm over the period from January 1998 to December 2007 were examined. Frequencies and means are presented in tables and bar charts. RESULTS: Two hundred sixty-four (92 male and 172 female patients) files were analyzed. The mean age was 56.15 years. Two hundred twenty-three (84.5%) aneurysms occurred in the abdominal aorta, followed by the descending aorta (7.5%), ascending aorta, (3.8%) and arch (1.9%). In 2.3% of cases, both the abdominal and thoracic aortas were affected. The male/female ratio was 1:1.9. Pain with swelling or a pulsatile mass was the predominant feature. More than 50% of the cases were diagnosed by means of ultrasonographic analysis. Sixty-one (23.1%) aneurysms were ruptured, and of this group, 44 (72.1%) patients died. Successful open surgical repair was done in 157 (59.5%) patients. Hypertension was a comorbidity in 137 (51.9%) cases. CONCLUSIONS: Aortic aneurysms in Kenya show abdominal segment and female predominance, occur 10 to 15 years earlier than in white populations, and carry high mortality from rupture. Hypertension was the leading associated risk factor. Ultrasonographic screening and control of blood pressure might be useful preventive measures.