Frederik H W Jonker1, Himanshu J Patel2, Gilbert R Upchurch3, David M Williams4, Daniel G Montgomery5, Thomas G Gleason6, Alan C Braverman7, Udo Sechtem8, Rossella Fattori9, Marco Di Eusanio10, Arturo Evangelista11, Christoph A Nienaber12, Eric M Isselbacher13, Kim A Eagle5, Santi Trimarchi14. 1. Thoracic Aortic Research Center, Policlinico San Donato, Italy; Department of Surgery, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands. Electronic address: jonkerfrederik@hotmail.com. 2. Cardiac Surgery Department, University of Michigan, Ann Arbor, Mich. 3. Division of Vascular and Endovascular Surgery, University of Virginia Health System, Charlottesville, Va. 4. Radiology Department, University of Michigan, Ann Arbor, Mich. 5. Cardiovascular Center, University of Michigan, Ann Arbor, Mich. 6. Division of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa. 7. Cardiovascular Division, Washington University School of Medicine, St. Louis, Mo. 8. Division of Cardiology, Robert-Bosch Krankenhaus, Stuttgart, Germany. 9. Division of Interventional Cardiology, San Salvatore Hospital, Pesaro, Italy. 10. Cardiac Surgery Department, University Hospital S. Orsola, Bologna, Italy. 11. Servei de Cardiologia, Hospital General Universitari Vall d'Hebron, Barcelona, Spain. 12. Department of Internal Medicine, University of Rostock, Rostock, Germany. 13. Thoracic Aortic Center, Massachusetts General Hospital, Boston, Mass. 14. Thoracic Aortic Research Center, Policlinico San Donato, Italy.
Abstract
OBJECTIVE: Acute type B aortic dissection (ABAD) can lead to visceral malperfusion, a potentially life-threatening complication. The purpose of this study was to investigate the presentation, management, and outcomes of ABAD patients with visceral ischemia who are enrolled in the International Registry of Acute Aortic Dissection. METHODS: Patients with ABAD enrolled in the registry between 1996 and 2013 were identified and stratified based on presence of visceral ischemia at admission. Demographics, medical history, imaging results, management, and outcomes were compared for patients with versus without visceral ischemia. RESULTS: A total of 1456 ABAD patients were identified, of which 104 (7.1%) presented with visceral ischemia. Preoperative limb ischemia (28% vs 7%, P < .001) and acute renal failure (41% vs 14%, P < .001) were more common among patients with visceral ischemia. Endovascular treatment and surgery were offered to 49% and 30% of the visceral ischemia cohort, respectively; remaining patients were managed conservatively. The in-hospital mortality was 30.8% for patients with visceral ischemia and 9.1% for those without visceral ischemia (odds ratio [OR] 4.44; 95% confidence interval [CI], 2.8-7.0, P < .0001). Mortality rates were similar after surgical and endovascular management of visceral ischemia (25.8% and 25.5%, respectively, P = not significant). Among the visceral ischemia group, medical management was a predictor of mortality in multivariate analysis (OR, 5.91; 95% CI, 1.2-31.0; P = .036). CONCLUSIONS: Patients with ABAD complicated by visceral ischemia have a high risk of mortality. We observed similar outcomes for patients treated by endovascular management versus surgery, whereas medical management was an independent predictor of mortality. Early diagnosis and intervention for visceral ischemia seems to be crucial.
OBJECTIVE:Acute type B aortic dissection (ABAD) can lead to visceral malperfusion, a potentially life-threatening complication. The purpose of this study was to investigate the presentation, management, and outcomes of ABAD patients with visceral ischemia who are enrolled in the International Registry of Acute Aortic Dissection. METHODS:Patients with ABAD enrolled in the registry between 1996 and 2013 were identified and stratified based on presence of visceral ischemia at admission. Demographics, medical history, imaging results, management, and outcomes were compared for patients with versus without visceral ischemia. RESULTS: A total of 1456 ABAD patients were identified, of which 104 (7.1%) presented with visceral ischemia. Preoperative limb ischemia (28% vs 7%, P < .001) and acute renal failure (41% vs 14%, P < .001) were more common among patients with visceral ischemia. Endovascular treatment and surgery were offered to 49% and 30% of the visceral ischemia cohort, respectively; remaining patients were managed conservatively. The in-hospital mortality was 30.8% for patients with visceral ischemia and 9.1% for those without visceral ischemia (odds ratio [OR] 4.44; 95% confidence interval [CI], 2.8-7.0, P < .0001). Mortality rates were similar after surgical and endovascular management of visceral ischemia (25.8% and 25.5%, respectively, P = not significant). Among the visceral ischemia group, medical management was a predictor of mortality in multivariate analysis (OR, 5.91; 95% CI, 1.2-31.0; P = .036). CONCLUSIONS:Patients with ABAD complicated by visceral ischemia have a high risk of mortality. We observed similar outcomes for patients treated by endovascular management versus surgery, whereas medical management was an independent predictor of mortality. Early diagnosis and intervention for visceral ischemia seems to be crucial.
Authors: Elizabeth L Norton; David M Williams; Karen M Kim; Minhaj S Khaja; Xiaoting Wu; Himanshu J Patel; G Michael Deeb; Bo Yang Journal: J Thorac Cardiovasc Surg Date: 2019-09-30 Impact factor: 5.209