Management and Outcomes of Non-A Non-B Aortic Dissection.

OBJECTIVE: The results of best medical treatment (BMT), endovascular based treatment (EBT), and total arch replacement (TAR) with frozen elephant trunk (FET) treatment in a single centre experience were reported in non-A non-B aortic dissection patients. METHODS: From January 2016 to May 2020, 215 consecutive patients with acute or subacute non-A non-B aortic dissection were enrolled. The primary endpoints were all cause death. Secondary endpoints included follow up adverse aortic event (AE), a composite of the outcomes of dissection related death, rupture, retrograde type A aortic dissection, stent graft induced new entry tear, secondary endoleak, and follow up re-intervention. Kaplan-Meier curves were used to evaluate associations between different treatments and outcomes. RESULTS: Among the 215 dissection patients, 127 (59.1%) received EBT, 42 (19.5%) received TAR + FET, and the remaining 46 (21.4%) received BMT. Thirty day mortality was higher in patients receiving TAR + FET (7.1%) than in those treated with EBT (1.6%) or BMT (2.2%) (p = .12). However, after a median follow up of 39.1 (27.0 - 50.7) months, no additional death was recorded in the TAR + FET group, while nine (7.3%) patients died in the EBT group and 14 (31.8%) died in the BMT group (p < .001). Specifically, EBT and TAR + FET showed no significant difference in midterm mortality rate, follow up AE, and re-intervention for complicated or uncomplicated dissection patients involving zone 2. For patients with uncomplicated non-A non-B aortic dissection involving zone 2, EBT could profoundly decrease the mortality rate, follow up AE and re-intervention when compared with BMT (p < .010 for all), although this difference was not statistically significant between TAR + FET and BMT. No statistical comparison was performed in patients with zone 1 involvement because of the limited number of patients. CONCLUSION: It was demonstrated that EBT or TAR + FET might be a viable strategy for non-A non-B aortic dissection patients.

Volumetric assessment is superior to axial measurements in estimating the outcome of patients with acute uncomplicated type B aortic intramural haematoma.

OBJECTIVES: Our goal was to investigate the accuracy of the two-dimensional and three-dimensional computed tomography imaging features in predicting the progression of acute uncomplicated type B aortic intramural haematoma (IMH). METHODS: This study retrospectively screened 140 patients diagnosed with acute uncomplicated type B IMH in our institution from January 2015 to December 2020. Patients were classified as exhibiting progression (aortic dissection, aortic rupture, aneurysm formation, ulcer-like projection depth >10 mm or >10% increase in the initial thickness of the aortic wall) and regression (completely or partially reabsorbed haematoma) based on follow-up computed tomography. RESULTS: During the 11.4-month follow-up [interquartile range (IQR), 2.6-17.8], 55 patients had haematoma progression. The progression group had higher haematoma volume (HV) and total lesion volume [94.8 (IQR, 80.0-108.2) cm3 vs 40.3 (IQR, 30.8-57.9) cm3; 278.0 (IQR, 238.6-369.3) cm3 vs 197.3 (IQR, 152.8-235.9) cm3, both P < 0.001) and longer lesion length [43.2 (IQR, 37.5-46.7) cm vs 30.4 (IQR, 28.1-37.6) cm, P < 0.001)] than the regression group. According to the area under the curve, HV > 66 cm3 is the greatest risk factor for haematoma progression. In multivariable analysis, HV was a powerful independent predictive factor for type B IMH progression, with a hazard ratio of 17.9 (95% confidence interval, 5.5-58.7; P < 0.001). CONCLUSIONS: Volumetric parameters may help to predict disease progression more precisely for patients with acute uncomplicated type B IMH compared to standard axial measurements, which might optimize the initial treatment and follow-up protocol.

Association between platelet counts and morbidity and mortality after endovascular repair for type B aortic dissection.

This study aimed to assess the association of postoperative platelet counts with early and late outcomes after thoracic endovascular aortic repair (TEVAR) for type B aortic dissection (TBAD). We retrospectively evaluated 892 patients with TBAD who underwent TEVAR from a prospectively maintained database. Postoperative nadir platelet counts were evaluated as a continuous variable, and a categorical variable (thrombocytopenia), which was defined as platelet count≤ the lowest 10% percentile (108 × 109/l). Multivariable logistic regression analyses were conducted to assess the impact of postoperative thrombocytopenia on early outcomes, and multivariable cox regression analyses on long-term mortality. Patients with postoperative thrombocytopenia experienced significantly higher rates of postoperative mortality, prolonged intensive care unit stay, death, stroke, limb ischemia, mesenteric ischemia, acute kidney injury (AKI), and puncture-related hematoma (P< .05 for each), but similar rates of immediate type I endoleak and spinal cord ischemia. Multivariable logistic analyses showed that postoperative thrombocytopenia was independently associated with postoperative stroke, limb ischemia, and AKI. Similar results were observed when postoperative nadir platelet count was modeled as a continuous predictor (P< .05 for each). By multivariable Cox analyses, postoperative thrombocytopenia was an independent predictor for long-term all-cause mortality (hazard ratio 2.72, 95% CI, 1.72-4.29, P< .001). For every 30 × 109/L decrease in postoperative platelet count, the risk of long-term all-cause mortality increased by 15% (HR 1.15; 95% CI 1.07-1.25; P< .001). Therefore, postoperative thrombocytopenia might be a useful tool for risk stratification after TEVAR.

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

BACKGROUND: 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). METHODS: 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. RESULTS: A total of 805 TBAD patients who underwent TEVAR were enrolled. Twenty-six (3.2%) patients died during hospitalisation. At the end of a median follow-up duration of 48.80 mon, 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). CONCLUSIONS: 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.

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

PURPOSE: The 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. METHODS: A 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. RESULTS: A 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. CONCLUSION: POD 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.

Risk stratification of ulcer-like projection in uncomplicated acute type B aortic intramural haematoma.

OBJECTIVES: This study aimed to investigate the morphological evolution and risk stratification of ulcer-like projection (ULP) in patients with uncomplicated acute type B aortic intramural haematoma. METHODS: A retrospective study was conducted on patients with uncomplicated acute type B intramural haematoma admitted in our institution from January 2015 to June 2020. The primary end points were adverse aortic events (AAE), including aortic rupture, aortic dissection, aortic aneurysm and ULP enlargement. RESULTS: The study cohort comprised 140 patients, including 62 (44%) and 78 (56%) patients with and without initial ULP, respectively. AAE occurred in 13 patients (9%) in the early term and 42 patients (33%) in the mid-term. Compared with patients without ULP, patients with initial ULP had no significant difference in early outcomes but a higher mid-term AAE rate [8% vs 11%, odds ratio (OR) 1.5, P = 0.47; 17% vs 55%, OR 6.0, P < 0.001]. Significantly higher AAE rate was observed in patients with high-risk ULP (depth ≥5.0 mm and located in the proximal aortic segments) than those with only low-risk ULP (depth <5.0 mm and/or located in the distal aortic segments) (87% vs 51%, OR 6.2, P = 0.014). In the multivariable analysis, high-risk ULP was an independent predictor of AAE (hazard ratio 2.8, P = 0.009). CONCLUSIONS: High-risk ULP is a rapidly evolving entity and a marker of AAE despite optimal medical therapy. Therefore, close follow-up and prompt intervention are recommended for patients with high-risk ULP.

Assessment of Liver Function for Evaluation of Short- and Long-Term Outcomes in Type B Aortic Dissection Patients Undergoing Thoracic Endovascular Aortic Repair.

Background and Aims: Patients with decreased liver function suffer from poor outcomes when undergoing procedures. We aimed to explore the impact of liver fibrosis identified by aspartate transaminase-to-platelet ratio index (APRI) and poor liver functional reserve assessed by a model of end-stage liver disease (MELD) and albumin-bilirubin(ALBI) score on the prognosis of patients with type B aortic dissection (TBAD) undergoing thoracic endovascular aortic repair (TEVAR). Methods: A retrospective analysis of a prospectively maintained database from 2010 to 2017 was performed. APRI > 0.5 was used to identify those with significant liver fibrosis. Logistic and Cox regression analyses were performed to investigate the association between liver fibrosis, MELD, and ALBI with adverse events. Results: TEVAR was performed on 812 TBAD patients including 35 with liver fibrosis and 777 without. Twenty-four (3.0%) patients deceased during hospitalization and 69 (8.8%) patients died after a median 48.2 months follow-up. Multivariable analysis revealed that liver fibrosis, MELD, and ALBI were independently associated with in-hospital [fibrosis: odds ratio (OR) 23.73, 95% confidence interval (CI) 8.89-63.33, P < 0.001; MELD: OR 1.08, 95% CI 1.03-1.14, P = 0.003; ALBI: OR 4.45; 95% CI 1.56-12.67, P = 0.005] and follow-up mortality [fibrosis: hazard ratio (HR) 4.69, 95% CI 1.93-11.42, P = 0.001; MELD: HR 1.07, 95% CI 1.04-1.10, P < 0.001; ALBI: HR 2.88, 95% CI 1.53-5.43, P = 0.001]. The association was further corroborated by a subgroup analysis. Conclusion: Liver fibrosis and poor liver functional reserve could significantly increase the morbidity and mortality after TEVAR. APRI, MELD, and ALBI should be calculated and routinely used for preoperative risk stratification. Strict preoperative preparation and elaborate postoperative care are necessary to improve these patients' prognosis.

Impact of Lymphocyte-Related Blood Parameters on Short- and Long-Term Outcomes of Patients Undergoing Thoracic Endovascular Aortic Repair.

Lymphocyte-related blood parameters (LRBP), including neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio, and lymphocyte-monocyte ratio, could reflect a patient's overall inflammatory status. We aimed to clarify the association between preoperative LRBP and outcomes of type B aortic dissection (TBAD) patients undergoing thoracic endovascular aortic repair (TEVAR). A total of 841 patients were enrolled from 2010 to 2017. Twenty-six (3.1%) patients died during hospitalization and 71 (8.7%) patients died after a median follow-up of 47.3 months. Multivariate analyses showed that the NLR was the only independent predictor for in-hospital death (odds ratio, 1.15; 95% confidence interval [CI], 1.09-1.22; P < .001); 4.1 was identified as the optimum threshold for NLR after applying the X-tile program. Propensity score matching (PSM) was performed to diminish bias and yielded 174 matched pairs. Neutrophil-lymphocyte ratio >4.1 was demonstrated to be independently associated with follow-up mortality before (hazard ratio [HR], 2.53; 95% CI, 1.44-4.43; P = .001) and after PSM (HR, 3.11; 95% CI, 1.35-7.15; P = .008). The relationship between LRBP and follow-up reintervention or stroke were not significant (P > .05 for both). Elevated NLR was an independent indicator for in-hospital and follow-up mortality in patients with TBAD undergoing TEVAR; this might provide additional risk stratification.

Timing and Outcome of Endovascular Repair for Uncomplicated Type B Aortic Dissection.

OBJECTIVE: This study aimed to determine the effect of intervention timing, from symptom onset to thoracic endovascular aortic repair (TEVAR), on early and late outcomes in high risk patients with uncomplicated type B aortic dissection (uTBAD). METHODS: The study retrospectively evaluated 267 uTBAD patients with high risk radiographic features who underwent pre-emptive TEVAR during the acute and subacute periods. Demographics, comorbidities, pre-operative imaging features, peri-procedural details, and follow up outcomes were analysed. RESULTS: Among the 267 pre-emptive TEVARs for high risk uTBAD, 130 were performed in the acute phase (1-14 days); and 137 in the subacute phase (15-90 days), from initial presentation. The mean age was 55.9 ± 11.0 years and 222 (83.1%) were men. The 30 day mortality rate in the acute group was five times higher than that in the subacute group (3.8% vs. 0.7%), although without statistically significant difference (p = .11). No statistically significant difference in 30 day outcomes (aortic rupture, retrograde type A dissection [RTAD], immediate type Ia endoleak, stroke, spinal cord ischaemia, and re-intervention) was noted (p > .05 for each). Of note, aortic rupture, RTAD, and disabling stroke were observed only in the acute group. Multivariable logistic analyses showed that intervention timing was not associated with 30 day outcomes. The median clinical follow up was 48.2 ± 25.9 months (range 1 - 106 months). There were no significant differences in all cause mortality, dissection related death, late intervention, or aortic related late events among timing cohorts (p > .05 for each). Furthermore, aortic remodelling, by analysing the flow status of the false lumen and evaluation of aortic diameters, either at the thoracic aorta level or the abdominal aorta level, was similar between the two groups. Multivariable Cox analyses showed that intervention timing was not associated with late outcomes. CONCLUSION: The present study indicates that TEVAR for high risk uTBAD in the acute phase was associated with a trend toward higher rates of early complications, while the long term outcomes were comparable with those of the subacute phase.

Prognostic dynamic nomogram integrated with metabolic acidosis for in-hospital mortality and organ malperfusion in acute type B aortic dissection patients undergoing thoracic endovascular aortic repair.

BACKGROUND: Organ malperfusion is a lethal complication in acute type B aortic dissection (ATBAD). The aim of present study is to develop a nomogram integrated with metabolic acidosis to predict in-hospital mortality and organ malperfusion in patients with ATBAD undergoing thoracic endovascular aortic repair (TEVAR). METHODS: The nomogram was derived from a retrospectively study of 286 ATBAD patients who underwent TEVAR from 2010 to 2017 at a single medical center. Model performance was evaluated from discrimination and calibration capacities, as well as clinical effectiveness. The results were validated using a prospective study on 77 patients from 2018 to 2019 at the same center. RESULTS: In the multivariate analysis of the derivation cohort, the independent predictors of in-hospital mortality and organ malperfusion identified were base excess, maximum aortic diameter ≥ 5.5 cm, renal dysfunction, D-dimer level ≥ 5.44 µg/mL and albumin amount ≤ 30 g/L. The penalized model was internally validated by bootstrapping and showed excellent discriminatory (bias-corrected c-statistic, 0.85) and calibration capacities (Hosmer-Lemeshow P value, 0.471; Brier Score, 0.072; Calibration intercept, - 0.02; Slope, 0.98). After being applied to the external validation cohort, the model yielded a c-statistic of 0.86 and Brier Score of 0.097. The model had high negative predictive values (0.93-0.94) and moderate positive predictive values (0.60-0.71) for in-hospital mortality and organ malperfusion in both cohorts. CONCLUSIONS: A predictive nomogram combined with base excess has been established that can be used to identify high risk ATBAD patients of developing in-hospital mortality or organ malperfusion when undergoing TEVAR.

Influence of Sex on Outcomes After Thoracic Endovascular Repair for Type B Aortic Dissection.

We aimed to investigate whether sex differences influence the clinical outcomes of patients who undergo thoracic endovascular aortic repair (TEVAR) for type B aortic dissection (TBAD). We retrospectively analyzed a prospectively maintained single-center cohort of patients with TBAD who underwent TEVAR between January 2010 and June 2017. We evaluated the in-hospital and long-term mortality and composite end point. Of the 913 patients, 793 (86.8%) were male and 120 (13.1%) were female. Compared to male patients, the female patients were older, more likely to have diabetes mellitus, but less likely to smoke or have hypertension. The proximal landing zone in 0 and 1 was higher in male patients (P = .023), who were more likely to require an aortic arch bypass. Endoleak, delirium, and ICU stay after stent-graft implantation were also more frequent in men. Sex factor was not associated with in-hospital or long-term mortality or the composite end point in the multivariable regression analyses and Cox regression model. The mean estimated survival time was similar between males and females (2462.9 ± 141.2 vs 2804.1 ± 117.4 days, P = .167) in the propensity score-matched cohort. Despite distinct characteristics between sex, there was no sex-related difference in long-term clinical outcomes after TEVAR for TBAD.

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.