Montgomery, Daniel

Background: Shock is a highly dreaded complication of type A acute aortic dissection (TAAAD). However, few data exist on its incidence and association with prognosis. Methods: We evaluated 2704 TAAAD patients [mean age 61.4 ± 14.5, (67.6%) male] from the International Registry of Acute Aortic Dissection. Results: Shock was present at arrival in 407 (15.1%) TAAAD patients. These patients demonstrated no difference in age (61.5 ± 15.2 with shock vs. 61.4 ± 14.4 years without; p=0.873), but were more likely to have history of hypertension (83.1% vs. 73.0%; p<0.001), atherosclerosis (36.5% vs. 21.7%, p<0.001) and diabetes (12.3% vs. 7.0%, p=0.001) than patients without shock. They had more surgical management (90.9% vs. 86.0%; p=0.007). In-hospital complications such as hypotension (49.8% vs. 28.6%; p<0.001), coma (11.4% vs. 5.8%; p<0.001), tamponade (33.6% vs. 18.2%; p<0.001) and myocardial ischemia/infarction (19.7% vs. 13.7%; p=0.006) were more common among shock patients. Overall in-hospital mortality (30.2% vs. 23.9%; p=0.007) and mortality by management (surgical: 24.6% vs. 19.1%; p=0.015; medical: 88.9% vs. 53.3%, p<0.001) were higher among shock patients. Independent predictors of in-hospital mortality in shock patients are displayed in Table 1. Among hospital survivors, Kaplan-Meier estimates of follow-up mortality were similar between groups (p=0.609). Conclusions: Shock occurred in 15.1% of patients with TAAAD and was associated with increased in-hospital morbidity and mortality, but not long-term mortality.

Introduction: Prior cardiac surgery can complicate the clinical presentation, diagnosis, and management of patients with type A aortic dissection (TAAAD). This report from the International Registry of Acute Aortic Dissection (IRAD) examines this hypothesis. Methods: 352 of 2289 TAAAD patients (15.4%) enrolled in IRAD had cardiac surgery prior to dissection, including coronary artery bypass grafting (CABG, 34.6%), aortic or mitral valve surgery (38.4%), aortic surgery (44.7%), and other cardiac surgery (18.1%). Results: Comparative differences in baseline demographics, clinical presentation, and management time are shown in Table 1. Patients with prior cardiac surgery were more likely to undergo CABG (p=0.006) or mitral valve replacement (p=0.001) at the time of dissection repair. Total cardiopulmonary bypass time was higher in patients with prior cardiac surgery (p<0.001); no difference was seen in cardiac arrest time (p=0.113) or cerebral ischemia time (p=0.286). In-hospital mortality was significantly higher for patients with prior cardiac surgery (33.5% vs. 24.0%, p70 (RR1.58, 95% CI 1.25-1.99), and medical management of acute dissection (RR 4.79, 95% CI 3.62-6.34). Kaplan-Meier analysis is shown in Figure 1. Conclusion: Prior cardiac surgery not only delays presentation and diagnosis of acute type A dissections, but is also an important adverse risk factor for early and late mortality.

Background: Stroke is one of the most dreaded complications of type A acute aortic dissection (TA-AAD). However, few data exist on its incidence and association with prognosis. Methods: We evaluated 2202 TA-AAD patients [pts, mean age 61.9 ± 14.4, 1487 (67.5%) male] from the International Registry of Acute Aortic Dissection (IRAD) to determine the incidence and prognostic influence of stroke in TA-AAD. Results: Stroke was present at arrival in 132 (6.0%) TA-AAD pts. Stroke pts were older (65±12 vs. 62±15 yrs; p=.002) and more likely to have hypertension (86% vs. 71%; p=.001) or atherosclerosis (29% vs. 22%; p=.042). While chest pain at arrival was less common (70% vs. 82%; p<.001), stroke pts presented more often with syncope (44% vs. 15%; p<.001), shock (14% vs. 7%; p=.005) or pulse deficit (51% vs. 29%; p=<.001). Arch vessels involvement was more frequent among the stroke pts (68% vs. 37%; p<.001). Stroke pts were treated less frequently by surgery (74% vs. 85%; p<.001). Hospital stay was significantly longer in patients presenting with stroke (median 17.9 versus 13.3 days, p<0.001). Stroke patients demonstrated more frequent in-hospital complications (Table) and higher mortality (adjusted OR 1.62, 95% CI .99-2.65, p=.055) Among hospital survivors, mortality at follow-up was similar in pts with and without stroke (adjusted HR 1.15, 95% CI 0.46-2.89, p=.761). Conclusions: Stroke occurred in greater than 1 of 20 pts with TA-AAD and was associated with increased morbidity and in-hospital, but not long-term mortality. Whether aggressive early intervention will reduce morbidity and improve mortality remains to be evaluated in future studies.

Introduction/Purpose: To examine trends in patient presentation, diagnosis and outcomes of acute aortic dissection over 15 years since the original report from the International Registry of Acute Aortic Dissection (IRAD). Methods: Patient data were collected at 28 international referral centers from 1996 up to the present. Trends were analyzed among 3275 patients divided according to date of enrollment into 6 equal groups and by Type: A (n=2110) or B (n=1165). Results: There was no change over time in the presenting complaints of severe or worst ever pain for Type A and Type B (90% and 96%, respectively), or in the incidence of chest pain ( 80% in Type A and 70% in Type B, respectively), with considerable overlap in chest vs. back pain between types. The report of pulse deficits did not change over time, present in 30% of Type A patients. Normal chest X-ray on presentation increased in Type A acute aortic dissection (AoD) from 13.7% to 31.3% over time (p-value for trend <0.001). In Type B the report of normal chest X-ray increased from 19.9% to 40.9% (p-value for trend <0.001). There were significant trends in initial imaging modalities for Type A: increased use of CT (from 49.4% to 71.6%, p-value for trend <0.001) and decreased use of TEE (from 45.3% to 25.4%, p-value for trend <0.001). For Type B, use of CT increased from 77.2% to 88.4% (p-value for trend .013). A decrease in overall mortality over time was significant for both Type A and Type B patients (see graph). Surgical mortality in Type A patients fell from 25.3% to 16.5% (p-value for trend 0 .003). Conclusions: No significant difference was seen over time in pain severity, chest pain, and presence of pulse deficits. The incidences of a normal chest X-ray, originally thought to be uncommon in dissection cases, increased over time to 30% in Type A and 40% in Type B AoD. Use of CT as the initial imaging modality increased for both Type A and Type B. Lastly, a significant decrease in overall mortality was seen for both Type A and Type B patients.

Background: Little is known about the relationship between Type A Acute Aortic Dissection (TAAAD) and pulse pressure (PP), defined as the difference between systolic and diastolic blood pressure. This study explores the association between PP and presentation, complications and outcomes of TAAAD patients. Methods: PP at hospital presentation was used to divide 1,960 non-iatrogenic TAAAD patients into quartiles: narrowed (≤39 mmHg; n=430), normal (40-56 mmHg; n=554), mildly elevated (57-75 mmHg; n=490) and markedly elevated (≥76 mmHg; n=486). Variables relating to index presentation and in-hospital outcomes were analyzed. Results: TAAAD patients (patients) in the narrowed PP quartiles were more frequently older and Caucasian while patients with markedly elevated PPs tended to be male and have a history of hypertension. Patients who demonstrated abdominal vessel involvement more commonly demonstrated elevated PPs whereas patients with narrowed PPs were more likely to have periaortic hematoma and/or pericardial effusion. Narrowed PPs were also correlated with higher incidences of hypotension, cardiac tamponade and mortality. TAAAD patients who were managed with endovascular and hybrid procedures and those with renal failure tended to have elevated PPs. No difference in aortic regurgitation at presentation was noted between groups. Conclusions: TAAAD patients in the middle two PP quartiles had better in-hospital outcomes than patients in the outer quartiles. Patients with narrowed PPs experienced more cardiac complications, particularly cardiac tamponade, while those with elevated PPs were more likely to have abdominal aortic involvement. Presenting PP offers a clue to different manifestations of AAD that may facilitate initial triage and care.

Background: The debate for the optimal treatment of complicated Type B Acute Aortic Dissection (TBAAD) is primarily focused upon open surgical intervention versus thoracic endovascular aortic repair (TEVAR). The technique of fenestration with stenting has been proposed to resolve malperfusion. This study evaluated post-procedural outcomes of all three approaches for TBAAD. Methods: TBAAD patients enrolled in the International Registry of Acute Aortic Dissection were stratified by management type: TEVAR, fenestration and stenting, and surgery. Results: Of the 552 patients with TBAAD, 231 (41.8%) underwent TEVAR, 214 (38.8%) standard open surgery, and 107 (19.4%) fenestration and stenting. TEVAR or fenestration and stenting were more likely to be performed in classic double barrel aortic dissection when compared to open surgery (73.2%, 76.6%, 52.8% respectively; p<0.001). Patients treated with open repair were less likely to have distal extension into the abdominal aorta than those with TEVAR or fenestration and stenting (47.7%, 62.7%, 86.4%, respectively; p<0.001). In-hospital mortality was similar between groups (11.7% TEVAR, 14.0% fenestration and stenting, 15.9% surgery). At five years, Kaplan-Meier post-discharge all-cause survival estimates were highest for TEVAR, followed by endovascular fenestration and finally open surgical intervention (85.2%, 78.3%, 67.2%, respectively; p=0.039). Conclusion: Patients treated by endovascular approaches, whether with flap fenestration or thoracic endovascular aortic repair, had lower five year mortality when compared to patients who required open repair in the setting of TBAAD. Either endovascular approach may be helpful in the treatment of TBAAD. Further research is needed to determine how much of the observed difference represents patient selection versus differential effects of treatment.