Predictors of Intervention and Mortality in Patients with Uncomplicated Acute Type B Aortic Dissection
Hunter M Ray, Christopher A Durham, Daniel Ocazionez, David Amaro-Driedger, Kristofer M Charlton-Ouw, Anthony L Estrera, Charles C Miller, Hazim J Safi, Ali Azizzadeh
The University of Texas Medical School at Houston, Houston, TX
INTRODUCTION:Patients with uncomplicated acute type B aortic dissection (uATBAD) have historically been managed with medical therapy. Recent studies suggested that high-risk patients with uATBAD may benefit from thoracic endovascular aortic repair (TEVAR). This study aims to determine the predictors of intervention and mortality in patients with uATBAD.
METHODS:All patients admitted with uATBAD from 2000-2014 were reviewed and those with computed tomographic angiography (CTA) imaging were included. Multi-planar reconstruction was used to obtain double orthogonal oblique measurements. All measurements were obtained by a specialized cardiovascular radiologist. The maximum aortic diameter, proximal descending thoracic aorta false lumen (FL) diameter, and area were recorded. Outcomes including the need for intervention and mortality were tracked over time. Data were analyzed by stratified Kaplan-Meier and multiple Cox regression analysis using SAS 9.4
RESULTS:During the study period, 294 patients with uATBAD were admitted with 162 having admission CTA imaging available for analysis. The cohort had an average age of 61.2 years (61%male, 53% Caucasian). The average follow up time was 3.9 years. A stratified analysis demonstrated the most sensitive cutoff for mortality was aortic diameter >44mm (p<0.0002), and it appeared to be a threshold effect with minimal additional information added by finer size stratification. FL diameter did not predict mortality in our series (p=0.4). Intervention-free survival, alternatively, appeared to decrease over the range of diameters from 35-44mm (p<0.008). A false lumen diameter >22mm was associated with decreased intervention-free survival (p<0.04). Diameter >44mm persisted as a risk factor (HR 8.7, p<0.0001) after adjustment for diabetes (6.5; p<0.0002), age (1.05/yr; p<0.0005), history of stroke (5.6; p<0.005), connective tissue disorder (2.3; p<0.008) and syncope on admission (9.6; p<0.05). The 1, 5, and 10 year intervention rate for patients with admission aortic diameter >44mm was 12.5%, 18.5%, and 27.7% compared to 4.6%, 13.7%, and 12.2% in the ≤44 mm group (P<0.001).
CONCLUSIONS:Aortic diameter >44mm is a predictor of mortality after adjustment for other significant risk factors. A FL diameter >22mm was associated with decreased intervention-free survival. uATBAD patients with these high-risk criteria should be considered for TEVAR.
Figure 1: Intervention Free Survival after uATBAD: Red ≤44 mm; Blue >44mm
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