The Role of Age in Complicated Acute Type B Aortic Dissection

doi:10.1016/j.athoracsur.2013.06.056

The Annals of Thoracic Surgery

Volume 96, Issue 6, December 2013, Pages 2129-2134

https://doi.org/10.1016/j.athoracsur.2013.06.056 Get rights and content

Background

Complicated acute type B aortic dissection (cABAD) generally requires urgent intervention. Advanced age is a risk factor for mortality after thoracic aortic intervention, including surgery for aortic dissection. The purpose of this study was to investigate the exact impact of increasing age on the management and outcomes of cABAD.

Methods

We analyzed the outcomes of 583 patients with cABAD enrolled in the International Registry of Acute Aortic Dissection (IRAD) between 1996 and 2012. All patients with cABAD were categorized according to age by decade and management type (medical, surgical, or endovascular treatment), and outcomes were subsequently investigated in the different age groups.

Results

The mean age of the cohort was 63.4 ± 14.2 years, 36% of patients (n = 209) were greater than 70 years of age and 64% (n = 374) were less than 70 years. The utilization of surgery and endovascular techniques progressively decreased with patient age, while the rate of medical management significantly increased with age (p < 0.001). The in-hospital mortality rates for complicated patients younger than 70 years versus 70 years or more were 10.1% versus 30.0% for endovascular treatment (p = 0.001), 17.2% versus 34.2% for surgical treatment (p = 0.027), and 14.2% versus 32.2% for medical treatment (p = 0.001). Age 70 years or greater was a predictor of in-hospital mortality in multivariate analysis (odds ratio 2.37, 95% confidence interval: 1.23 to 4.54, p = 0.010).

Conclusions

Advanced age has a dramatic impact on the management and outcomes of patients with cABAD. A nonsignificant trend toward lower mortality after endovascular management was observed, both for younger patients and for elderly patients.

Section snippets

Patient Selection

The IRAD registry is an ongoing multicenter registry that includes patients with AAD at 30 large referral centers; its rationale and methods have previously been described [11]. For the present study, we included all patients with cABAD enrolled in the IRAD registry between January 1996 and October 2012. We defined cABAD as one or more of the following complications: shock, periaortic hematoma, spinal cord ischemia, preoperative mesenteric ischemia/infarction, acute renal failure, limb

Demographics and Medical History

Among the 1,348 ABAD patients enrolled in the IRAD registry, 583 patients presented with complications (43.8%). The mean age of complicated ABAD patients was 63.4 ± 14.2 years (Fig 1); 36% of patients (n = 209) were aged 70 years or more and 64% (n = 374) were younger than 70 years. The mean age of patients treated with medical management was 67.8 ± 13.1 years, versus 59.1 ± 14.9 years for patients undergoing surgery, and 61.2 ± 13.5 years for patients treated with endovascular management (p <

Comment

Our analysis shows that increasing patient age has a dramatic impact on the management and outcomes of cABAD. The rate of surgical or endovascular interventions progressively decreased with age whereas the rate of medical management significantly increased with age. There was a nonsignificant trend toward lower mortality after endovascular treatment, but patients older than 70 years had a significantly increased mortality rate, irrespective of the type of management.

Although patients with

References (35)

C.E. Anagnostopoulos et al.
Aortic dissections and dissecting aneurysms
Am J Cardiol
(1972)
M.W. Wheat
Acute dissecting aneurysms of the aorta: diagnosis and treatment—1979
Am Heart J
(1980)
J.A. Elefteriades et al.
Management of descending aortic dissection
Ann Thorac Surg
(1999)
J. Golledge et al.
Acute aortic dissection
Lancet
(2008)
R. Fattori et al.
Complicated acute type B dissection: is surgery still the best option? A report from the International Registry of Acute Aortic Dissection
J Am Coll Cardiol Intv
(2008)
S. Trimarchi et al.
Role of age in acute type A aortic dissection outcome: report from the International Registry of Acute Aortic Dissection (IRAD)
J Thorac Cardiovasc Surg
(2010)
J.P. Umana et al.
Is medical therapy still the optimal treatment strategy for patients with acute type B aortic dissections?
J Thorac Cardiovasc Surg
(2002)
J. McPhee et al.
Endovascular treatment of ruptured abdominal aortic aneurysms in the United States (2001–2006): a significant survival benefit over open repair is independently associated with increased institutional volume
J Vasc Surg
(2009)
M.L. Schermerhorn et al.
Population-based outcomes of open descending thoracic aortic aneurysm repair
J Vasc Surg
(2008)
Z.M. Arthurs et al.
Functional and survival outcomes in traumatic blunt thoracic aortic injuries: an analysis of the National Trauma Databank
J Vasc Surg
(2009)

R.H. Mehta et al.

Acute type A aortic dissection in the elderly: clinical characteristics, management, and outcomes in the current era

J Am Coll Cardiol

(2002)

D. Mukherjee et al.

Implications of periaortic hematoma in patients with acute aortic dissection (from the International Registry of Acute Aortic Dissection)

Am J Cardiol

(2005)

A. Khoynezhad et al.

Midterm results of endovascular treatment of complicated acute type B aortic dissection

J Thorac Cardiovasc Surg

(2009)

H.J. Patel et al.

Long-term results of percutaneous management of malperfusion in acute type B aortic dissection: implications for thoracic aortic endovascular repair

J Thorac Cardiovasc Surg

(2009)

S. Kische et al.

Endovascular treatment of acute and chronic aortic dissection: midterm results from the Talent Thoracic Retrospective Registry

J Thorac Cardiovasc Surg

(2009)

R.J. Feezor et al.

Early outcomes after endovascular management of acute, complicated type B aortic dissection

J Vasc Surg

(2009)

J.P. Verhoye et al.

Complicated acute type B aortic dissection: midterm results of emergency endovascular stent-grafting

J Thorac Cardiovasc Surg

(2008)

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2023, Annals of Vascular Surgery
The aim of the study was to analyze the clinical characteristics of patients with Stanford type B aortic dissection (TBAD) and risk factors for poor prognosis after thoracic endovascular aortic repair (TEVAR).
Clinical records for patients with TBAD presenting to a medical center between March 1, 2012 and July 31, 2020 were reviewed. Clinical data including demographics, comorbidities, and postoperative complications were obtained from electronic medical records. Comparative analysis and subgroup analysis were performed. A logistic regression model was used to analyze prognostic factors in patients with TBAD after TEVAR.
TEVAR was performed on all 170 patients with TBAD, and poor prognosis was identified in 28.2% (48/170) of cases. Patients with a poor prognosis were younger (38.5 [32.0, 53.8] years vs. 55.0 [48.0, 62.0] years, P < 0.001), had higher systolic blood pressure (SBP) (138.5 [127.8, 152.8] mm Hg vs. 132.0 [120.8, 145.3] mm Hg, P = 0.013) and more complicated aortic dissection patients (19 [60.4] vs. 71 [41.8], P = 0.029) than those without a poor prognosis. According to the results of binary logic regression analysis, the possibility of a poor prognosis after TEVAR decreased with each 10 years increase in age (odds ratio: 0.464, 95% confidence interval: 0.327–0.658, P < 0.001).
There is an association between younger age and a poor prognosis after TEVAR in patients with TBAD, with the condition that those with poor prognoses have higher SBP and more complicated cases. In younger patients, postoperative follow-up should be more frequent, and complications should be managed in time.
Twenty-five years of observations from the International Registry of Acute Aortic Dissection (IRAD) and its impact on the cardiovascular scientific community
2023, Journal of Thoracic and Cardiovascular Surgery
The International Registry of Acute Aortic Dissection (IRAD) celebrated its 25th anniversary in January 2021. This study evaluated IRAD's role in promoting the understanding and management of acute aortic dissection (AD) over these years.
IRAD studies were identified, analyzed, and ranked according to their citations per year (c/y) to determine the most-cited IRAD studies and topics. A systematic search of the literature identified cardiovascular guidelines on the diagnosis and management of acute AD. Consequently, IRAD's presence and impact were quantified using these documents.
Ninety-seven IRAD studies were identified, of which 82 obtained more than 10 cumulative citations. The median c/y index was 7.33 (25th-75th percentile, 4.01-16.65). Forty-two studies had a greater than median c/y index and were considered most impactful. Of these studies, most investigated both type A and type B AD (n = 17, 40.5%) and short-term outcomes (n = 26, 61.9%). Nineteen guideline documents were identified from 26 cardiovascular societies located in Northern America, Europe, and Japan. Sixty-nine IRAD studies were cited by these guidelines, including 38 of the 42 most-impactful IRAD studies. Among them, partial thrombosis of the false lumen as a predictor of postdischarge mortality and aortic diameters as a predictor of type A occurrence were determined as most-impactful specific IRAD topics by their c/y index.
IRAD has had and continues to have an important role in providing observations, credible knowledge, and research questions to improve the outcomes of patients with acute AD.
Age-related differences in acute aortic dissection
2022, Journal of Vascular Surgery
The present study investigated the differences in clinical characteristics, treatments, and outcomes of patients with acute aortic dissection (AAD) in different age groups.
The present single-center retrospective study was conducted from August 2014 to August 2020. The patients were divided into three groups: age <45 years (young group), age 45 to 59 years (middle-age group), and age >59 years (elderly group). Type A (TAAD) and type B (TBAD) aortic dissection were evaluated separately using the latest definitions.
The mean age at onset was 52.4 years in our cohort of 602 patients. The young group included a large proportion of male patients (86%). The body mass index and body surface area were higher in the young group. The proportion of non–true lumen blood supply of branches on the abdominal aorta in the young group (27%-55%) was greater than that in the others. In the young group, the distal extent of dissection in 84% of TAAD and 89% of TBAD exceeded the abdominal aortic branch cluster (AABC) compared with 36% of TAAD and 58% of TBAD in the elderly group. The multivariate analysis revealed that age <45 years (odds ratio, 5.15; P < .001) and D-dimer level (odds ratio, 1.05; P = .001) were risk factors for intimal flap tear exceeding the AABC. The proportion of visceral and lower limb malperfusion increased from 4.8% to 36.9% as the intimal flap tear exceeded the AABC.
Compared with middle-age and elderly patients, young patients with AAD had two characteristics (ie, obesity and an intimal flap that had frequently exceeded the branches of the aorta). These two factors resulted in a greater proportion of non–true lumen blood supply, increased visceral and lower limb malperfusion, and an increase in potential associated risks.
Utility of age, creatinine, and ejection fraction score in patients with type B aortic dissection undergoing thoracic endovascular aortic repair
2020, International Journal of Cardiology
Citation Excerpt :
TEVAR is also an interventional surgery that involves placing a stent-graft in the thoracic or thoracoabdominal aorta for the treatment of TBAD. Previous studies showed that older age, renal and cardiac dysfunction are predictors of poor outcomes in patients with aortic dissection [12–14]. We thus believed that ACEF score could be considered as a risk-stratified tool in TBAD patients undergoing TEVAR.
Older age, renal and cardiac dysfunction are predictors of poor outcome in aortic dissection. The aim of this study was to evaluate the association of the age, creatinine and ejection fraction (ACEF) score with adverse events in patients with type B aortic dissection (TBAD) undergoing thoracic endovascular aortic repair (TEVAR).
The study enrolled 605 patients from January 2010 to July 2015, who were classified into three groups according to the tertiles of ACEF score: Tertile 1 (≤0.77, n = 204), Tertile 2 (0.77–0.96, n = 205) and Tertile 3 (>0.96, n = 196). The association between ACEF, AGEF (age, glomerular filtration rate and ejection fraction) and the updated version of the ACEF (ACEF II) score with adverse events was analyzed.
After a median 3.4 years follow-up, 63 (10.4%) patients died. Multivariable analysis revealed that ACEF score was independently associated with long-term mortality (adjusted hazard ratio = 3.54; 95% confidence interval, 2.09–6.01; p < 0.001). ACEF, AGEF and ACEF II score had similar predictive ability for both in-hospital and long-term death. The in-hospital mortality (1.5% vs. 1.0% vs. 6.6%, p = 0.001) were significantly higher in Tertile 3. In addition, cumulative long-term mortality in Tertile 3 was significantly higher than that in Tertile 1 and 2 (Log-Rank = 23.74; p < 0.001).
ACEF score could be served as an useful and relatively simple tool for pre-TEVAR risk stratification in TBAD patients.
Ethnic disparities in outcomes of patients with complicated type B aortic dissection
2018, Journal of Vascular Surgery
Citation Excerpt :
In fact, we found that when adjusted for age, ethnic differences in mortality were no longer statistically significant, although they still existed. Older age is a predictor of mortality in patients with TBAD, so our significantly older white population may have been at higher risk for this reason.24 However, the fact that African Americans presented at a younger age was troubling as it suggested an earlier onset of the disease process.
The objective of this study was to evaluate the difference in outcomes after endovascular intervention in patients with complicated type B aortic dissection (TBAD) based on ethnicity and blood pressure control.
Between 2012 and 2016, there were 126 patients who underwent endovascular procedures for complicated TBAD at a single-institution quaternary referral center. Patients self-identified as African American (n = 53), white (n = 70), and Asian (n = 3). African American and white patients were compared on a number of variables, including age, ethnicity, insurance type, blood pressure, comorbidities, number of previous interventions, and number of antihypertension medications they were taking before intervention. Primary outcomes were survival and need for reintervention.
Kaplan-Meier estimates for survival for African Americans vs whites were 94% vs 89%, 91% vs 83%, 89% vs 79%, and 89% vs 76% at 30 days, 1 year, 3 years, and 5 years, respectively (P = .05). African Americans were younger overall (52.5 ± 11 years) vs whites (63.7 ± 14.7 years; P < .0001). African Americans required a significantly greater number of reinterventions (P = .007). They also had higher rates of chronic kidney disease (P = .01), smoking (P = .03), and cocaine use (P = .02) and were more likely to be on Medicaid (P = .02). Hypertension was poorly controlled in both groups, with the percentage of patients with uncontrolled hypertension (systolic >140 mm Hg) preoperatively, postoperatively, and 30 days after intervention at 32%, 32%, and 39%. There was no significant difference between the cohorts in uncontrolled hypertension preoperatively (P = .39) or postoperatively (P = .63). However, more African Americans had uncontrolled hypertension at 30 days (African Americans, 49%; whites, 31%; odds ratio, 2.1; P = .09). African Americans were taking a greater number of antihypertension medications at presentation than whites (P = .01) and specifically had higher use rates of beta blockers (P = .02), diuretics (P = .02), and angiotensin-converting enzyme inhibitors (P = .04).
African Americans with TBAD present at a younger age than their white counterparts do and have a survival advantage up to at least 5 years. However, African Americans have a higher rate of reintervention that is probably associated with poor blood pressure control despite taking more antihypertension medications both before and after the repair. It appears that optimal medical therapy is difficult to achieve in all groups. More aggressive medical management is needed, particularly more so in African Americans, which may in turn decrease the number of interventions and potentially improve long-term survival.
Acute type B aortic dissection complicated by visceral ischemia
2015, Journal of Thoracic and Cardiovascular Surgery
Citation Excerpt :
Overall in-hospital mortality with surgical versus endovascular management was similar; however, the IRAD is an observational registry, so patient groups were probably not identical. Generally, the utilization of endovascular techniques for the management of complicated ABAD has dramatically increased and seems to lead to reduced mortality.17-22 Although, to our knowledge, no other studies have compared outcomes of endovascular versus surgical methods for ABAD with visceral ischemia, a few reports have evaluated these techniques for acute mesenteric ischemia in general.
Acute type B aortic dissection (ABAD) can lead to visceral malperfusion, a potentially life-threatening complication. The purpose of this study was to investigate the presentation, management, and outcomes of ABAD patients with visceral ischemia who are enrolled in the International Registry of Acute Aortic Dissection.
Patients with ABAD enrolled in the registry between 1996 and 2013 were identified and stratified based on presence of visceral ischemia at admission. Demographics, medical history, imaging results, management, and outcomes were compared for patients with versus without visceral ischemia.
A total of 1456 ABAD patients were identified, of which 104 (7.1%) presented with visceral ischemia. Preoperative limb ischemia (28% vs 7%, P < .001) and acute renal failure (41% vs 14%, P < .001) were more common among patients with visceral ischemia. Endovascular treatment and surgery were offered to 49% and 30% of the visceral ischemia cohort, respectively; remaining patients were managed conservatively. The in-hospital mortality was 30.8% for patients with visceral ischemia and 9.1% for those without visceral ischemia (odds ratio [OR] 4.44; 95% confidence interval [CI], 2.8-7.0, P < .0001). Mortality rates were similar after surgical and endovascular management of visceral ischemia (25.8% and 25.5%, respectively, P = not significant). Among the visceral ischemia group, medical management was a predictor of mortality in multivariate analysis (OR, 5.91; 95% CI, 1.2-31.0; P = .036).
Patients with ABAD complicated by visceral ischemia have a high risk of mortality. We observed similar outcomes for patients treated by endovascular management versus surgery, whereas medical management was an independent predictor of mortality. Early diagnosis and intervention for visceral ischemia seems to be crucial.

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Original articleAdult cardiacThe Role of Age in Complicated Acute Type B Aortic Dissection

Background

Methods

Results

Conclusions

Section snippets

Patient Selection

Demographics and Medical History

Comment

Am J Cardiol

Am Heart J

Ann Thorac Surg

Lancet

J Am Coll Cardiol Intv

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Vasc Surg

J Vasc Surg

J Vasc Surg

J Am Coll Cardiol

Am J Cardiol

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Vasc Surg

J Thorac Cardiovasc Surg

Original article
Adult cardiac
The Role of Age in Complicated Acute Type B Aortic Dissection