Outcomes of Medical Management for Uncomplicated Isolated Abdominal Aortic Dissection
Hunter M. Ray, MD, Harleen K. Sandhu, MD, MPH, Charles C. Miller, PhD, Ali Azizzadeh, MD, Hazim J. Safi, MD, Kristofer M. Charlton-Ouw, MD
The University of Texas Health Science Center at Houston (UT Health), McGovern Medical School, Houston, TX
OBJECTIVES:
Spontaneous isolated abdominal aortic dissection (IAAD) is rare. The natural history and optimal treatment of IAAD is poorly understood given the sparsity and heterogeneity of currently available literature, consisting mostly of case reports and small series. In this study we compare our experience with management of IAAD and thoracic type B aortic dissection.
METHODS:
Patients presenting with IAAD from 1998-2014 were reviewed, excluding iatrogenic and traumatic dissections. All patients were initially managed with anti-impulse therapy, with indications for surgery including rupture, aortic expansion, malperfusion, and/or intractable pain. Survival was analyzed by Kaplan-Meier and multiple cox-regression analysis.
RESULTS:
During the study period 33 patients (67% male; mean age 59 years) presented with IAAD. Presentation was acute in 18(55%), symptomatic in 28(85%), aneurysmal degeneration was present in 16(49%), and penetrating atherosclerotic ulcer (PAU) was noted in 3(10%). IAAD was mainly infrarenal (97%) with iliac involvement in 37%(11/30). Seven (21%) required surgery (5 open and 2 endovascular) with no in-hospital mortality. Over the mean follow-up of 114 months, 8 were readmitted with 2 reinterventions performed. Overall and reintervention-free survival at 10 years for medical versus surgical management of IAAD was 90% and 82% versus 67% and 67% (p=.282 and p=.633), respectively. Acuity, management approach, intramural hematoma, PAU and iliac extension were not associated with reintervention over 5 years. Compared to patients with acute thoracic type B aortic dissection (ATBAD), the need for surgery in acute IAAD was not different (4/18(22%) versus 108/397(27%)), but was associated with higher mortality (HR 1.9, p<0.001)regardless of extent. Survival between surgically managed and uncomplicated medically managed acute IAAD versus ATBAD was significantly different (p=0.003).
CONCLUSIONS:
Based on our experience, the largest single-center series to date, medical management of uncomplicated IAAD demonstrated excellent long-term survival. Patients with IAAD had improved survival compared to those with ATBAD.
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