Cocaine use is associated with worse outcomes in patients treated with thoracic endovascular repair for type B aortic dissection

Population risk profile analysis of acute uncomplicated type B aortic dissection patients undergoing thoracic endovascular aortic repair

BACKGROUND

Uncomplicated type B aortic dissection (unTBAD) comprises the estimated majority of type B aortic dissection (TBAD), presenting without any of the complications associated with complicated TBAD (coTBAD). Although first-line treatment for coTBAD is thoracic endovascular aortic repair (TEVAR), and despite the fact that TEVAR has proven its safety and effectiveness in the treatment of unTBAD, unTBAD is still being predominantly managed conservatively with medical therapy, with a small proportion of patients being offered TEVAR.

AIMS

The main scope of this review is to highlight the evidence in the literature of the demographic characteristics and associated co-morbidities of unTBAD patients undergoing TEVAR in order to produce a risk stratification system to achieve favourable outcomes.

METHODS

A comprehensive literature search was conducted using multiple electronic databases including PubMed, Ovid, Scopus, and EMBASE.

RESULTS

Multiple demographic characteristics and associated co-morbidities of unTBAD patients affecting TEVAR outcomes were identified, assessed, and investigated, including age, gender, race, genetics, medical conditions, such as hypertension and diabetes, and lifestyle factors such as smoking. Most factors were associated with increased risks of mortality and morbidity, while others, such as race, were identified as being protective against those when it comes to TEVAR.

CONCLUSION

Despite the favourable results yielded by TEVAR in unTBAD, there remains a grey area concerning its management. Thus, it is important to incorporate the demographics and co-morbidities of unTBAD patients' when into clinical judgement when assessing indications for TEVAR intervention to ensure optimum results can be achieved.

Progressive Aortic Enlargement in Medically Managed Acute SVS/STS Type B Aortic Dissections with Visceral Aortic Involvement

BACKGROUND

Aortic remodeling of the thoracic aorta has been studied in patients treated with medical or endovascular therapy for the treatment of acute aortic dissections; however, particular attention has not yet focused on identifying specific growth patterns and rates across all aortic zones. Additionally, previous studies have not delineated between dissections with and without visceral aortic involvement, and we hypothesize that these two cohorts may exhibit distinct differences. The aim of this study is to investigate aortic behavior over time in medically managed acute SVS/STS Type B dissections with visceral aortic involvement, and identify potential associations of subsequent aortic behavior with clinical outcomes.

METHODS

A single-center retrospective review was performed of all patients between 2010-2020 with acute SVS/STS Type B aortic dissections with visceral aortic involvement that were not surgically managed. Short-axis centerline measurements of the true/false lumen and total aortic diameter (TAD) were taken at standardized locations relative to aortic anatomy within each aortic zone, including non-dissected zones. Measurements were taken at the time of diagnosis and at six subsequent yearly intervals. Diameter changes over time were evaluated using repeated measures mixed models linear growth analysis. Aortic enlargement was classified by growth in TAD≥5mm in either the thoracic (Thoracic Segment Enlargement [TSE], Zone 0-4) or visceral segments (Visceral Segment Enlargement [VSE], Zone 5-9).

RESULTS

A total of 78 patients were identified with a median length of follow-up of 3.3 years (interquartile range [IQR]1.3-6.6 years). Follow-up past 5 years was seen in 31% of the cohort. For the entire cohort, mean thoracic growth in TAD was 2.0±2.0 mm/year and visceral growth in TAD 2.5±2.4 mm/year. TSE was observed in 65% of patients, with a median time until onset of 0.8 years (IQR 0.4-2.3 years). VSE was observed in 57% of the cohort, with a median time until onset of 1.6 years (IQR 0.9-3.3 years). Repeat measures mixed models linear growth analysis identified significant predictable linear growth in all aortic zones except for the non-dissected Zones 0-2. Odds for TSE are significantly increased in patients with known genetically triggered aortic conditions (GenTACs) (OR 2, 95% CI 1.8-4.5, p=0.044) and in cases where the dissection entry tear was in either Zone 1 or 2 (OR 4.8, 95% CI 1.2-8.4, p=0.044). In adjusted regression analysis, odds for intervention in the thoracic aorta were significantly increased in patients with rapid TSE in Zone 3 (OR 3.6 [1.1-8.4], p=0.045). Similarly, odds for intervention targeting the visceral aortic segment were significantly increased in patients with Zone 9 VSE (OR 9.3, 95% CI 1.1-13.3, p=0.014). Odds for 5-year all-cause mortality were significantly increased in cases with large thoracic aneurysms (OR 6.1, 95% CI 1.1-14.9, p=0.042).

CONCLUSIONS

Aortic enlargement was present in the majority of patients with medically managed acute SVS/STS Type B aortic dissections with visceral aortic involvement, with analysis demonstrating predictable linear growth in all dissected zones. Patients with aortic instability demonstrated higher gross changes in diameter in addition to higher yearly rates of change compared to all comers. Odds for enlargement were impacted by both patient demographic and anatomic dissection characteristics. Growth in Zone 3 and Zone 9 significantly increased odds for aortic intervention. Odds for 5-year mortality were significantly increased in the presence of large thoracic aneurysms. Results highlight risk of progressive degeneration beyond acute phase in SVS/STS Type B aortic dissections with visceral aortic involvement, with life-long surveillance remaining crucial in management of dissections.

Association of Mental Health Disorders and Aortic Dissection

INTRODUCTION

Mental health disorders (MHD), including substance abuse, have been associated with aortic dissection (AD). Aneurysmal degeneration in the residual untreated aorta after both open and endovascular treatment is not uncommon in AD. Thus, diligent long-term follow-up is necessary and MHD may play a role in treatment plan and surveillance. The impact of MHD on management, outcomes and follow-up after AD treatment is unknown and here we sought to evaluate these associations.

METHODS

A retrospective review was performed on all patients diagnosed with Stanford Type A and B dissections from 2008 to 2018 at a tertiary referral center. MHD was defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-V). Patient demographics, procedural characteristics, and outcomes were analyzed.

RESULTS

A total of 649 non-traumatic aortic dissections were identified in the study timeframe. The cohort consisted of 51% Type A (n = 334) dissection and 49% Type B (n = 315) dissection. Mental health disorders were present in 49.3% of the cohort. Notably, the timing of MHD diagnosis relative to development of AD is unknown in the majority of patients. Within the Type A population, a MHD was present in 50.6% (N = 162) of patients, of which the most common indication for MHD was the presence of antidepressant or antipsychotic medication (28.6%). In patients with Type A dissections, the presence of a MHD did not significantly affect the rate of index hospitalization intervention (68%) or long-term mortality (12.5% in patients with a MHD). Within the Type B population, a MHD was present in 49.4% (n = 158) of patients, of which the most common indication for MHD was the presence of antidepressant or antipsychotic medication (30.5%). In patients with Type B dissections, the presence of a MHD did not significantly affect the rate of index hospitalization intervention (50.3% in patients with a MHD) or long-term mortality (10.1% in patients with a MHD). The overall participation in follow-up care was not significantly decreased based on the presence of a MHD compared to those without a MHD (1.66 ± 2.16 years vs. 1.68 ± 2.20 years, P = 0.93).

CONCLUSION

MHD is more prevalent in AD patients than in the general population, but demonstrating a causal relationship between MHD and development/progression of AD is challenging. Despite a high prevalence of MHD in AD patients, in-hospital mortality and follow-up compliance was similar to non-MHD patients.

Complicated acute type B aortic dissection: update on management and results

BACKGROUND

The role of thoracic endovascular aortic repair (TEVAR) has evolved and is now firmly established as a mainstay of therapy for acute complicated type B aortic dissection (acTBAD). However, several important issues remain unresolved including the optimal timing, sizing, graft selection, coverage length and utilization of adjunctive therapies to address false lumen perfusion. Therefore, the purpose of this study was to provide a contemporary perspective on the management and results for TEVAR of acTBAD.

METHODS

All TEVAR patients (N.=159) with acTBAD from a single high-volume, academic medical center were analyzed. Comparative results across time-dependent cohorts (2005-2009 [N.=43] vs. 2010-2014 [N.=56] vs. 2015-2020 [N.=60]) are presented.

RESULTS

30-day mortality was 13%(N.=21) with a trend towards improvement over time (2005-2009, 18% vs. 2010-2020, 12%; P=0.1). Similarly, incidence of postoperative complications also declined: 2005-2009, 70% vs. 2010-2020, 36%(P-trend=0.08). One and 2-year freedom from aorta-related reintervention was 78±7% and 73±9% and did not differ across cohorts (log-rank P=0.5). Respective one and 5-year survival was 75±3% and 64±7%, but significantly improved with time (log-rank P<0.001). The corresponding one and five-year freedom from aorta-related mortality was 82±4% and 78±7% but did not change during the study interval (log-rank P=0.3).

CONCLUSIONS

Outcomes for TEVAR of acTBAD continue to improve over time. This time-dependent analysis delineates how results have changed due to increasing experience, technologic evolution, and maturation of the peer reviewed evidence. These results along with the evidence-based review provided herein, provide an update on the management and results of TEVAR of acTBAD while highlighting specific controversies unique to the management of this challenging clinical problem.

Cocaine-Related Aortic Dissection: what do we know?

Introduction

Cocaine use is known to be associated with an increased risk for vascular diseases. It is likely to trigger or increase the risk for an aortic dissection. We conducted an analysis of 45 cases of cocaine-related aortic dissection to further characterize the clinical features and outcomes of this patient cohort.

Methods

Our study cohort of 45 patients consisted of 11 cases from our institutional database and 34 published case reports.

Results

The observed cases of acute aortic dissection related to cocaine use showed a high proportion of young (41.3±8.67 years) and male (88.9%) patients. Most of the cases (75%) were classified as Stanford type A. Also, in 75% of the cases, cocaine use was prevalent for more than one year. Median time from last cocaine use to onset of symptoms was one hour. In-hospital mortality was 21.4%, while additional 11.9% of the cases died before arriving at the hospital.

Conclusion

Acute aortic dissection related to cocaine use occurs in predominantly young male patients and has a dismal outcome when compared to all comer series.