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

The role of geriatric nutritional risk index in predicting survival of type B aortic dissection patients after thoracic endovascular aortic repair

BACKGROUND

The geriatric nutritional risk index (GNRI) is a reliable indicator of patients' nutrition status and has been shown to be valuable in predicting the outcome of patients with various cardiovascular diseases. This study explored the association between perioperative GNRI and the prognosis of type B aortic dissection (TBAD) patients receiving thoracic endovascular aortic repair (TEVAR).

METHODS

A total of 1,157 consecutive patients who underwent TEVAR between January 2007 and August 2019 were included, with data from 789 patients analyzed. The GNRI was used to measure nutritional status. Patients were categorized into five groups based on the GNRI quintile. The study's endpoints included all-cause mortality, aortic-related adverse events (ARAEs), and major adverse cardiovascular and cerebrovascular events (MACCEs) at 30 days, 1 year, and 5 years. The univariate and multivariate Cox regression analyses the effect of GNRI on the endpoints. Kaplan-Meier survival analysis was conducted to assess the incidence of these endpoints across the five groups, and restricted cubic spline (RCS) analysis was used to examine the non-linear relationship between GNRI and all-cause mortality.

RESULTS

The Kaplan-Meier survival analyses revealed that the risk of 1-year and 5-year all-cause mortality was highest in the Q1 group among the five groups (P = 0.009 and P = 0.002, respectively). However, there was no significant difference in 1-year and 5-year ARAEs and MACCEs (all P > 0.05). Multivariate Cox analysis showed that continuous GNRI was independently associated with 5-year all-cause death (HR = 0.97, 95% CI: 0.95-1.00; P = 0.027). Compared with the Q1 group, the Q2 (HR = 0.22, 95% CI: 0.06-0.80; P = 0.021) and Q4 groups (HR = 0.26, 95% CI: 0.08-0.81; P = 0.020) had lower risks of 1-year all-cause mortality. The Q2 group (HR = 0.38, 95% CI: 0.18-0.83; P = 0.015) and Q3 group (HR = 0.46, 95% CI: 0.22-0.96; P = 0.039) were also observed to have a lower risk of 5-year all-cause mortality than the Q1 group. In the subgroup analyses, chronic kidney disease (CKD) showed significant interaction (P-interaction < 0.001). Besides, the RCS analysis identified a "U"-shaped relationship between GNRI and all-cause mortality of TBAD patients following TEAVR.

CONCLUSIONS

TBAD patients undergoing TEVAR showed a strong correlation between perioperative low GNRI and higher risks of 1-year and 5-year all-cause mortalities. TBAD patients with a too low GNRI should receive particular attention.

Predictive value of cumulative SII for MACE in STEMI patients after PCI

The systemic immune-inflammation index (SII) has been used effectively to effectively assess the prognosis of patients with a variety of diseases. But few evidence on the relationship between SII and long-term prognosis of myocardial infarction. We thus aimed to evaluate the relationships of cumulative exposure to SII and its accumulation time course with major adverse cardiovascular events (MACE) events in patients with acute myocardial infarction after percutaneous coronary intervention. To evaluate the predictive value of SII in MACE events in patients with acute myocardial infarction. A total of 480 patients with acute ST-elevation myocardial infarction who underwent emergency coronary angiography at the Department of Cardiology, Affiliated Hospital of Hebei University from August 2022 to August 2023 were enrolled in this study. Eighteen patients were lost to follow-up, with a loss rate of 3.8%. Time-weighted cumulative SII was calculated as the weighted sum of the mean SII value for each time interval, then normalized by total exposure duration, the exposure duration was from hospitalization to 1-year follow-up. Duration of high SII exposure was defined as the duration with high SII and ranged from hospitalization to 1-year follow-up. The time course of SII accumulation was categorized by the combination of time-weighted cumulative SII < or ≥ median and SII slope. At 1-year follow-up, after adjusting for potential confounders, the time-weighted cumulative SII was divided into 2 groups. The S2 group which is above the median had a higher risk of MACE (hazard ratio, 1.090; 95% confidence interval 1.035-1.149), the high time-weighted cumulative SII group with a positive slope had a higher risk of MACE (hazard ratio, 4.096; 95% confidence interval 1.851-9.065). Long-term cumulative exposure to SII increases the risk of MACE in patients with acute ST-elevation myocardial infarction undergoing coronary angiography, and late high SII results in a higher risk of MACE events at the same time-weighted cumulative SII, underscoring the importance of late inflammation control.

Biomarkers to predict the outcomes of surgical intervention for aortic dissection

PURPOSE

Aortic dissections and repairs are associated with high rates of mortality. The aim of this review is to summarize the literature concerning the prognostic ability of various preoperative biomarkers for patients undergoing surgical repair of the thoracic and abdominal aorta to elucidate whether these biomarkers could improve the selection of surgical candidates.

METHODS

Relevant biomarkers were selected if they had predictive value in inflammatory disease processes and/or cardiovascular disease. Full-text articles available in English on PubMed that related these biomarkers to the prognosis of aortic repair following aortic dissection were examined.

RESULTS

For patients who underwent repair for type A dissection, a preoperative elevated SII was associated with inferior 30-day survival (hazard ratio: 3.532, 95% confidence interval: 1.719-7.255, p = 0.001) and increased rates of adverse cardiovascular events. Elevated preoperative IL-6 and D-dimer levels were independently associated with single-organ dysfunction, multiorgan dysfunction, and death. The use of a combination of markers was a stronger predictor. The areas under the curve (AUCs) for the specified IL-6 and D-dimer cutoff values were 0.901 and 0.817, respectively, whereas the AUC reached 0.936 when IL-6 was combined with D-dimer. For patients who underwent thoracic endovascular aortic repair (TEVAR) for type B dissection, an elevated postoperative systemic immune-inflammation index (SII) was an independent risk factor for aorta-related complications, graft failure, and significantly inferior freedom from aortic-related mortality. A combination of elevated preoperative and postoperative SII values was again predictive of in-hospital adverse outcomes and follow-up complications, including endoleaks, branch artery stenosis, distal aortic expansion, aortic rupture, and death (p = 0.0016). An elevated preoperative neutrophil‒leukocyte ratio (NLR) is associated with an increased incidence of early postoperative adverse events and poor survival.

CONCLUSIONS

Inflammatory markers seem to have predictive ability for postoperative outcomes after aortic repair in type A dissections. Further studies should compare these biomarkers to determine the best predictive marker for individual disease states and surgeries.

Effect of Statins on the Prognosis After Thoracic Endovascular Aortic Repair for Patients With Acute Type B Aortic Dissection

OBJECTIVE

To analyze the clinical efficacy of long-term statin therapy following thoracic endovascular aortic repair (TEVAR) in patients with acute type B aortic dissection (ATBAD).

METHODS

We retrospectively analyzed data from 645 patients treated between January 2005 and June 2022, dividing them into Statin Group (n=330) and Non-statin Group (n=315) based on whether they received long-term postoperative statin therapy. Patients were further categorized based on median admission low-density lipoprotein cholesterol (LDL-C) levels into High and Low LDL-C Groups to assess the effect of statins on the prognosis of ATBAD patients after TEVAR.

RESULTS

The cohort had an average age of 53.44±11.42 years old, and 81.71% were male. Statin therapy significantly reduced occurrences of all-cause death (3.03% vs 8.57%, p=0.002) and aorta-related death (0.91% vs 3.81%, p=0.015), particularly in patients with high admission LDL-C levels. In addition, patients with statin therapy had a lower incidence of aorta-related adverse events (ARAE) (4.24% vs 11.11%, p=0.001). Kaplan-Meier analysis indicated statins reduced 5-year cumulative incidence rates of all-cause death and ARAE (all Log-rank p<0.05). These trends were sustained after adjustment. Multivariate Cox analysis confirmed that statin therapy was associated with reduced risks of all-cause and aorta-related deaths, as well as ARAE.

CONCLUSION

Long-term statin therapy appears to decrease the risk of all-cause and aorta-related death in ATBAD patients after TEVAR, particularly patients with high admission LDL-C levels. Patients with lower LDL-C levels at admission have a reduction of aorta-related death in the follow-up period. Statin therapy also was associated with a lower incidence of ARAE in follow-up. These findings suggest that statins might be crucial in improving long-term outcomes in this patient population.

CLINICAL IMPACT

Long-term statin therapy administered to patients with acute type B aortic dissection (ATBAD) following thoracic endovascular aortic repair (TEVAR) demonstrates a substantial reduction in both all-cause and aorta-related mortality. Notably, this therapeutic benefit is most evident in patients presenting with elevated low-density lipoprotein cholesterol (LDL-C) levels at admission. Furthermore, statin therapy is associated with a decreased incidence of aorta-related adverse events during follow-up. These findings underscore the pivotal role of statin therapy in enhancing long-term clinical outcomes for ATBAD patients undergoing TEVAR, thereby contributing to improved patient care and prognosis.

Management of Systemic Inflammatory Response Syndrome After Cardiovascular Interventions. Diagnostic, Prognostic, and Therapeutic Implications

A substantial number of patients may experience systemic inflammatory response syndrome (SIRS) and related adverse events after transcatheter aortic valve implantation and endovascular aortic aneurysm repair. Although a clear etiology has not been established, endothelial disruption and tissue-ischemic response secondary to the foreign material may represent the trigger events. A latency period (0 to 48 hours) may occur between the initial injury and onset of symptoms mirroring an initial local response followed by a systemic response. Clinical presentation can be mild or severe depending on external triggers and characteristics of the patient. Diagnosis is challenging because it simulates an infection, but lack of response to antibiotics, negative cultures are supportive of SIRS. Increased in-hospital stay, readmissions, major cardiovascular events, and reduced durability of the device used are the main complications. Treatment includes non-steroidal anti-inflammatory drugs or corticosteroids. In conclusion, further studies are warranted to fully explore pathophysiologic mechanisms underpinning SIRS and the possibility of enhancing device material immune compatibility to reduce the inflammatory reaction of the host tissue.

Postoperative Prognostic Nutritional Index and Fibrinogen Could Well Predict Poor Prognosis of Acute Type A Aortic Dissection Patients After Surgery

INTRODUCTION

Inflammatory and immunological factors play pivotal roles in the prognosis of acute type A aortic dissection. We aimed to evaluate the prognostic values of immune-inflammatory parameters in acute type A aortic dissection patients after surgery.

METHODS

A total of 127 acute type A aortic dissection patients were included. Perioperative clinical data were collected through the hospital's information system. The outcomes studied were delayed extubation, reintubation, and 30-day mortality. Multivariate logistic regression analysis and receiver operating characteristic analysis were used to screen the risk factors of poor prognosis.

RESULTS

Of all participants, 94 were male, and mean age was 51.95±11.89 years. The postoperative prognostic nutritional indexes were lower in delayed extubation patients, reintubation patients, and patients who died within 30 days. After multivariate regression analysis, the postoperative prognostic nutritional index was a protective parameter of poor prognosis. The odds ratios (95% confidence interval) of postoperative prognostic nutritional index were 0.898 (0.815, 0.989) for delayed extubation and 0.792 (0.696, 0.901) for 30-day mortality. Low postoperative fibrinogen could also well predict poor clinical outcomes. The odds ratios (95% confidence interval) of postoperative fibrinogen were 0.487 (0.291, 0.813) for delayed extubation, 0.292 (0.124, 0.687) for reintubation, and 0.249 (0.093, 0.669) for 30-day mortality.

CONCLUSION

Postoperative prognostic nutritional index and postoperative fibrinogen could be two promising markers to identify poor prognosis of acute type A aortic dissection patients after surgery.

Association between preoperative systemic immune inflammation index and postoperative sepsis in patients with intestinal obstruction: A retrospective observational cohort study

BACKGROUND

Sepsis is a severe complication that results in increased morbidity and mortality after intestinal obstruction surgery. This study examined the role of preoperative systemic immune inflammation index (SII) for postoperative sepsis in intestinal obstruction patients.

METHODS

Data on patients who underwent intestinal obstruction surgery were collected. SII was determined and separated into two groups (≤1792.19 and >1792.19) according to the optimal cut-off value of SII for postoperative sepsis. The odds ratio (OR) is calculated for the correlation between SII and postoperative sepsis. Additional analyses were used to estimate the robustness of SII.

RESULTS

A total of 371 intestinal obstruction patients undergoing surgery were included in the final cohort, and 60 (16.17%) patients developed postoperative sepsis. Patients with an SII ＞1792.19 had a significantly higher risk for developing postoperative sepsis after multivariable adjustment [adjusted odds ratio = 2.12, 95% confidence interval: [1.02-4.40]]. The analysis of interaction showed no correlation between the preoperative SII and postoperative sepsis regarding age, hypertension, American Society of Anesthesiologists classification, blood loss, albumin, hemoglobin, creatinine, and leukocyte (all interactions p > .05). In subgroup analysis, all statistically significant subgroups showed that SII was a risk factor for postoperative sepsis (all p < .05). The analyses of subgroups and interactions revealed that the interaction effect of a preoperative SII ＞1792.19 and postoperative sepsis remained significant. A sensitivity analysis confirmed the robustness of the results.

CONCLUSIONS

A preoperative SII ＞ 1792.19 was a risk factor for postoperative sepsis in patients undergoing intestinal obstruction surgery.

Prognostic Value of Systemic Inflammation Response Index in Acute Type A Aortic Dissection

BACKGROUND

The study aimed to evaluate the prognostic value of preoperative systemic inflammation response index (SIRI) for acute type A aortic dissection (ATAD) following open surgery.

METHODS AND RESULTS

Totally, 410 ATAD patients underwent open surgery from 2019 to 2021 were enrolled in the study. Among the patients, the in-hospital mortality was 14.4%. Cox regression (95%CI 1.033-1.114p < 0.001) and receiver operating characteristic curve analysis (AUC = 0.718, p < 0.001) demonstrated the prognostic role of SIRI for in-hospital mortality after surgery. The optimal cut-off value of SIRI for in-hospital mortality was identified as 9.43 by maximally selected Log-Rank statistics. The patients were divided into high SIRI group (SIRI ≥ 9.43) and low SIRI group (SIRI < 9.43)) after the linear inverse relationship between SIRI and hazard ratio for in-hospital mortality was demonstrated by restricted cubic spline analysis (p = 0.0742). The Kaplan-Meier analysis illustrated that in-hospital mortality increased significantly in high SIRI group (p < 0.001). In addition, elevating SIRI was significantly associated with the incidence of coronary sinus tear (95%CI 1.020-4.475p = 0.044). Furthermore, the incidence rate of postoperative complications including renal failure (p < 0.001) and infection (p = 0.019) was higher in high SIRI group.

CONCLUSION

The study indicated that preoperative SIRI could provide strong prognostic value for in-hospital mortality in ATAD patients following open surgery. Thus, SIRI was a promising biomarker for risk stratification and management prior to open surgery.

Coronary artery disease as an independent predictor of short-term and long-term outcomes in patients with type-B aortic dissection undergoing thoracic endovascular repair

Background and aims

Previous studies reported a high prevalence of concomitant coronary artery disease (CAD) in patients with Type B aortic dissection (TBAD). However, there is too limited data on the impact of CAD on prognosis in patients with TBAD. The present study aimed to assess the short-term and long-term impact of CAD on patients with acute or subacute TBAD undergoing thoracic endovascular aortic repair (TEVAR).

Methods

We retrospectively evaluated 463 patients with acute or subacute TBAD undergoing TEVAR from a prospectively maintained database from 2010 to 2017. CAD was defined before TEVAR by coronary angiography. Multivariable logistic and cox regression analyses were performed to evaluate the relationship between CAD and the short-term as well as long-term outcomes.

Results

According to the results of coronary angiography, the 463 patients were divided into the following two groups: CAD group (N = 148), non-CAD group (N = 315). In total, 12 (2.6%) in-hospital deaths and 54 (12%) all-cause deaths following a median follow-up of 48.1 months were recorded. Multivariable analysis revealed that CAD was an independent predictor of in-hospital major adverse clinical events (MACE) (odd ratio [OR], 2.33; 95% confidence interval [CI], 1.07-5.08; p = 0.033), long-term mortality [hazard ratio (HR), 2.11, 95% CI, 1.19-3.74, P = 0.011] and long-term MACE (HR, 1.95, 95% CI, 1.26-3.02, P = 0.003). To further clarify the relationship between the severity of CAD and long-term outcomes, we categorized patients into three groups: zero-vessel disease, single-vessel disease and multi-vessel disease. The long-term mortality (9.7 vs. 14.4 vs. 21.2%, P = 0.045), and long-term MACE (16.8 vs. 22.2 vs. 40.4%, P = 0.001) increased with the number of identified stenosed coronary vessels. Multivariable analysis indicated that, multi-vessel disease was independently associated with long-term mortality (HR, 2.38, 95% CI, 1.16-4.89, P = 0.018) and long-term MACE (HR, 2.79, 95% CI, 1.65-4.73, P = 0.001), compared with zero-vessel disease.

Conclusions

CAD was associated with short-term and long-term worse outcomes in patients with acute or subacute TBAD undergoing TEVAR. Furthermore, the severity of CAD was also associated with worse long-term prognosis. Therefore, CAD could be considered as a useful independent predictor for pre-TEVAR risk stratification in patients with TBAD.

Acute aortic syndromes: An internist's guide to the galaxy

Acute aortic syndromes (AASs) are severe conditions defined by dissection, hemorrhage, ulceration or rupture of the thoracic aorta. AASs share etiological and pathophysiological features, including long-term aortic tissue degeneration and mechanisms of acute aortic damage. The clinical signs and symptoms of AASs are unspecific and heterogeneous, requiring large differential diagnosis. When evaluating a patient with AAS-compatible symptoms, physicians need to integrate clinical probability assessment, bedside imaging techniques such as point-of-care ultrasound, and blood test results such as d-dimer. The natural history of AASs is dominated by engagement of ischemic, coagulative and inflammatory pathways at large, causing multiorgan damage. Medical treatment, multiorgan monitoring and outcome prognostication are therefore paramount, with internal medicine playing a key role in non-surgical management of AASs.

Short- and Mid-Term Survival Prediction in Patients with Acute Type A Aortic Dissection Undergoing Surgical Repair: Based on the Systemic Immune-Inflammation Index

Purpose

The postoperative survival of patients with acute type A aortic dissection (aTAAD) remains unsatisfactory. The current study developed an easy-to-use survival prediction model and calculator.

Methods

A total of 496 patients with aTAAD undergoing surgical repair were included in this study. The systemic immune-inflammation index (SII) and other clinical features were collected and subjected to logistic and Cox regression analyses. The survival prediction model was based on Cox regression analyses and exhibited as a nomogram. For convenience of use, the nomogram was further developed into calculator software.

Results

We demonstrated that a higher preoperative SII was associated with in-hospital death (OR: 4.116, p < 0.001) and a higher postoperative overall survival rate (HR: 2.467, p < 0.001) in aTAAD patients undergoing surgical repair. A survival prediction model and calculator based on SII and four other clinical features were developed. The overall C-index of the model was 0.743. The areas under the curves (AUCs) of the 1- and 3-month and 1- and 3-year survival probabilities were 0.73, 0.71, 0.71 and 0.72, respectively. The model also showed good calibration and clinical utility.

Conclusion

Preoperative SII is significantly associated with postoperative survival. Based on SII and other clinical features, we created the first easy-to-use prediction model and calculator for predicting the postoperative survival rate in aTAAD patients, which showed good prediction performance.

Evaluation of the efficiency of the systemic immune-inflammation index in differentiating parapneumonic effusion from empyema

AIM

To evaluate the effectiveness of the systemic immune-inflammation index (SII) and other biomarkers in distinguishing parapneumonic effusion (PPE) and empyema.

METHODS

Patients who were thought to have pleural effusion secondary to pneumonia in the pediatric emergency department (PED) between 2004 and 2021 were retrospectively evaluated. The patients were divided into two groups as empyema and PPE. The efficacy of infection markers in predicting empyema was compared.

RESULTS

Fifty-nine patients (59.3% male) were included in the study. Forty-three (72.9%) patients were in the PPE and 16 (27.1%) were in the empyema group. Length of hospital stay and pleural fluid thickness measured with thoracic ultrasonography were significantly higher in the empyema group (p = 0.018 and p = 0.002, respectively). The mean SII was 1902.73 ± 1588.87 in PPE patients, while it was 6899.98 ± 6678 in empyema patients (p = 0.009). C-reactive protein (CRP), white blood cell (WBC) count, absolute neutrophil count (ANC), and neutrophil-lymphocyte ratio (NLR) ​​were significantly higher in the empyema group; absolute lymphocyte count (ALC) and lymphocyte-monocytes ratio (LMR) were significantly lower than the PPE group. When the best cut-off values of inflammation markers are determined according to the area under the curve, the highest odds ratios suggesting empyema were found in SII, LMR, CRP, and ANC, respectively.

CONCLUSION

Inflammation markers can be useful in predicting empyema. The best markers were found to be SII, LMR, CRP, and ANC. High SII is one of the practical diagnostic markers that can be used differentiate empyema from PPE in PED.