Risk Stratification In Patients With Spontaneous Isolated Abdominal Aortic Dissection
Thoetphum Benyakorn, MD FRCST, Jasmin Etafo, Sherene Shalhub, MD FACS MPH.
University of Washington, Seattle, WA, USA.
Objective: Spontaneous isolated abdominal aortic dissection (IAAD) is a rare entity with poorly defined risk factors and their impact on outcomes. The presentation, symptoms, and natural history vary widely. Moreover, management varies from medical management to emergent operative repair. The purpose of this study is to compare and stratify the risk factors, specifically on the associated features and clinical outcome, in complicated IAAD (cIAAD) and uncomplicated IAAD (uIAAD).
Methods: Clinical and administrative records for patients presenting to an academic medical system with IAAD between 1996 and 2018 were reviewed. Data abstraction included demographics, comorbidities, presentation, imaging findings, and outcomes. Patients were excluded if the dissection was trauma-related, or the imaging review showed a dissection originating in the thoracic aorta. An IAAD with rupture, malperfusion, and/or aneurysm greater than 5 cm on presentation was designated as complicated IAAD (cIAAD). These cases were compared to uncomplicated IAADs (uIAADs).
Results: A total of 36 patients presented with IAAD (mean age 55.7±14.9 years, 52.8% male). In 4 cases (11.1%), the etiology was iatrogenic. cIAAD occurred in 11 (30.5%) cases. There were no differences in sex, or prevalence of hypertension and smoking between cIAAD and uIAAD. Patients with cIAAD were significantly younger at presentation, had larger abdominal aortic aneurysms, had more genetically triggered aortopathy, and died at a younger age (Table 1). Moreover, morphologically, the cIAAD cohort had more dissections beyond the aortic bifurcation and concomitant arterial aneurysms compared to the uIAAD cohort. In contrast, patients with uIAAD had significantly more coronary artery disease and a trend of higher prevalence of concurrent malignancy and cirrhosis/hepatitis/pancreatitis (Table 1). Patients with cIAAD had more surgical repairs, while most uIAAD patients were managed medically.
Conclusions: IAAD has distinct clinical phenotypes most likely related to the underlying etiology. Understanding these risk factors is essential to stratify the risk of individuals with IAAD and direct individualized management.
| Cohort | Complicated | Uncomplicated | |||
| N=36 | N=11 | N=25 | P | ||
| Age at IAAD | 55.7±14.9 | 47.7±10.3 | 59.2±15.3 | 0.03 | |
| Male | 19 (52.8%) | 5 (45.5) | 14 (56) | 0.559 | |
| Comorbidities | Hypertension | 19 (52.8%) | 5 (45.5) | 14 (56) | 0.559 |
| Coronary artery disease | 10 (27.8) | 0 | 10 (40) | 0.014 | |
| Concurrent malignancy | 5 (13.9) | 1 (9.1) | 4 (16) | 0.581 | |
| Cirrhosis, hepatitis, or pancreatitis | 5 (13.9) | 0 | 5 (20) | 0.11 | |
| Abdominal aortic aneurysm | 8 (22.2) | 6 (54.5) | 2 (8) | 0.002 | |
| Genetically triggered | 7 (19.4) | 6 (54.4) | 1 (4) | <.001 | |
| Current or past smoker | 14 (38.9) | 4 (36.4) | 10 (40) | 0.837 | |
| Presentation/ management | Symptomatic IAAD | 25 (69.4) | 9 (81.8) | 16 (64) | 0.285 |
| Hospitalization related to IAAD | 21 (58.3) | 9 (81.8) | 12 (48) | 0.058 | |
| Medical management | 26 (72.2) | 3 (27.3) | 23 (92) | <.001 | |
| Open surgical Repair | 5 (14) | 5 (45.5) | 0 | <.001 | |
| Endovascular Repair | 6 (16.7) | 3 (27.3) | 3 (12.5) | 0.257 | |
| Mortality | Duration of follow up | 5.0±5.0 | 2.9±3.4 | 5.5±5.4 | 0.162 |
| Age at death | 65.9±18.5 | 47.9±12.5 | 77.2±10.8 | 0.001 | |
| IAAD related | 5 (13.9) | 4 (36.4) | 1 (4.2) | 0.038 | |
| Malignancy | 4 (11.1) | 0 | 4 (16.7) | 0.29 | |
| Pneumonia | 2 (5.5) | 0 | 2 (8.3) | 1 | |
| MI | 1 (2.7) | 1 (9.1) | 0 | 0.356 | |
| GI hemorrhage | 1 (2.7) | 0 | 1 (4.2) | 1 | |
| Morphology | Dissection beyond aortic bifurcation | 14 (38.9) | 8 (72.7) | 6 (24) | 0.01 |
| >1 visceral branch involvement | 2 (5.6) | 2 (18.2) | 0 | 0.087 | |
| Concomitant aneurysms | 8 (22.2) | 6 (54.5) | 2 (8) | <0.001 | |
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