A retrospective study was conducted on prospectively collected data of BAD patients undergoing TEVAR from January 2011 to April 2017 at Wuhan Asia Heart Hospital (Wuhan, China). Patients with medical history of aortic diseases, Marfan syndrome or other connective tissue diseases, bicuspid aortic valve, iatrogenic or traumatic dissection, syphilis and other inflammatory diseases of the aorta, cancer, pregnancy, severe renal or respiratory or cardiac insufficiency were excluded. Patients who experienced acute myocardial infarction, cerebrovascular disease (CVD) or major surgical procedures before or after 30 days of study enrolment were also excluded.

Data on demographic characteristics, medical history, presenting symptoms, biochemical and imaging findings, treatment strategies, medication use, blood pressure at discharge, in-hospital outcomes and follow-up outcomes were collected. Discharge blood pressure was the last recorded blood pressure obtained within 24 h before or at hospital discharge.

The study was performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. All procedures were approved by the Ethics Committee of Wuhan Asia Heart Hospital. Written informed consent were obtained from all participants.

All patients were treated with TEVAR and optimal antihypertensive medications. Each of the patients was measured by contrast-enhanced computed tomography (CT) before TEVAR procedure. TEVAR was performed according to the procedure described by Dake et al. [11] Successful TEVAR procedure was defined as technically successful placement of the stent graft at the intended target location without an endoleak [12]. Intravenous beta blockers and calcium channel blockers (CCB) were administered alone or combination to reduce SBP to < 120 mmHg as initial therapy in the intensive care unit. Intravenous medications were replaced by oral antihypertensive drugs including beta blockers, angiotensin-converting enzyme inhibitors (ACEI), angiotensin receptor blockers (ARB), CCB and diuretics, either alone or in combination. The decision when, whether and how to give oral antihypertensive medications was at the discretion of the treating physician according to current guidelines and the best clinical practice. Hypertension was defined as a self-reported diagnosis of hypertension, treatment with antihypertensive agents or having a clinical record of a blood pressure ≥ 140/90 mmHg⁶. All subjects were classified into the acute group (≤ 14 days), sub-acute group (14–90 days) and the chronic group (> 90 days), based on the time interval from the symptom onset date to the procedure date [3]. Body mass index (BMI) is equal to weight (kg) divided by the square of height (m²). Overweight was defined as a BMI between 25 kg/m² and 30 kg/m² and obesity as a BMI ≥30 kg/m² [13].

All patients were followed up by 3 clinical cardiologists. Data on symptoms, medications, laboratory measurements, electrocardiograms, echocardiograms and contrast-enhanced CT findings were collected through electronic data capture and telephone interviews. Thirty days and 90 days after the completion of TEVAR were designed to follow up. Ninety-day ARAE was used for statistical analysis in our study.

ARAE were defined as aortic related death, new dissection, progression of aortic dissection (aortic rupture, necessitating surgical procedure or TEVAR after discharge), malperfusion (bowel ischemia, renal ischemia and lower limb ischemia), paraplegia, major stroke or endoleaks [14‐17].

One-Sample Kolmogorov-Smirnov test was used to evaluate the distribution of all variables. Age was a normal continuous variable and was presented as means ± standard deviations. SBP, DBP, pulse pressureand heart rate at discharge were non-normal continuous variables and were presented as medians (quartile 1 to quartile 3 [Q1–Q3]). Sex, the classification of BMI, tobacco abuse, alcohol abuse, hypertension, DM, PAD, CVD, CAD, dyslipidemia, stage of BAD, operative procedure, number of stentand medications at discharge were categorical variables and they were shown as counts and percentages. Independent samples t-test, Mann-Whitney U test and Chi-square test were used to compare the differences betweennormal continuous variables, non-normal continuous variables and categorical variables, respectively. SBP as a continuous variable predictor of the endpoint of 90-day ARAE was analyzed by receiver operator characteristic (ROC) curves. The optimal cut-off points of SBP to differentiate ARAE from non-ARAE outcomes were determined using Youden’s index, which equally weighs sensitivity and specificity and maximizes the number of correctly classified patients. Overall ARAE-free probabilities were estimated using the Kaplan-Meier method and comparisons between groups were carried out using the log-rank test. The relationship between SBP at discharge and 90-day ARAE was assessed using univariate and multiple cox proportional hazard analysis. Logistic analysis was performed to identify independent risk factors for poor blood pressure control. Hazard rates (HR) and odds ratios (OR) were assessed with a 95% confidence interval (CI), and a two-tailed p < 0.05 was considered statistically significant. All data analyses were performed using the statistical software Statistical Product and Service Solution (SPSS 19.0 for windows, Chicago, Illinois, USA).

There were 292 consecutive BAD patients who were initially treated with TEVAR in Wuhan Asia Heart Hospital. Among them, 1 patients who presented with other aortic lesions besides BAD, 1 with medical history of aortic diseases, 1 with Marfan syndrome, 1 with syphilitic aortic disease, 3 with iatrogenic or traumatic dissection, 5 with cancer, 3 with renal insufficiency, 2 patients who had CVD within 30 days of study enrolment, 4 patients who underwent surgical procedures within 30 days of study enrolment and 2 patients without follow-up records were excluded. Finally, 269 patients were enrolled.

All 269 patients completed 90 days of follow-up, and the unadjusted ARAE-free rates at 90-day was 95.1 ± 1.3%. The mean age of all patients was 55 ± 10 years, and 84.0% of the patients were males. Patient demographics, clinical characteristics, treatment, blood pressure and medications at discharge are outlined in Table 1.

We constructed ROC curves of the SBP for the diagnosis of 90-day follow-up ARAE to find the optimal cut-off value with the highest Youden index. The optimal cut-off value of SBP at discharge for 90-day ARAE was 131 ≈ 130 mmHg. Subsequently, all the patients were divided into SBP ≤ 130 mmHg group and SBP > 130 mmHg group when the 90-day outcomes were analysed.

Cumulative ARAE-free rate in all patients was 95.1 ± 1.3% at 90-day follow-up. The probability of 90-day ARAE-free as categorized by SBP using Kaplan-Meier analysis showed significant differences among the two groups (SBP ≤ 130 mmHg group vs. SBP > 130 mmHg group, p = 0.012), as shown in Fig. 1. Multivariate Cox analysis was performed. SBP at discharge (HR 3.780; 95% CI 1.236–11.556; p = 0.020) was the only significant predictor of 90-dayARAE.

All patients were divided into 2 groups according to the significant cut-off value of SBP at discharge: SBP ≤ 130 mmHg group and SBP > 130 mmHg group. Table 1 shows the details of patient characteristics categorized by SBP group. BMI, CVD, stage of BAD, operative procedures and number of stents were significantly different between the two groups. Hybrid operation (OR 2.046; 95%CI 1.015–4.122; p = 0.045) and insertion of ≥2 stents (OR 2.950; 95%CI 1.172–7.426; p = 0.022) were demonstrated to be independently associated with poor SBP control (SBP > 130 mmHg) by Logistic analysis (Table 2).

There are several limitations to the present study. First, the monitor of ambulatory blood pressure and blood pressure variability providng insight into overall blood pressure control for outpatient during follow-up were not performed. Second, the present study is a single-center study and multi-center studies in type BAD are required in the future. Finally, the choice of antihypertensive medications was leftat the physician’s discretion and subject to potential selection bias.