The Impact of Arch Involvement in Acute Type B Aortic Dissection
Hunter M. Ray, MD, Kristofer M. Charlton-Ouw, MD, Anthony L. Estrera, MD, Charles C. Miller, PhD, Hazim J. Safi, MD, Ali Azizzadeh, MD.
The University of Texas Medical School at Houston, Houston, TX, USA.
INTRODUCTION: The affect of aortic arch involvement in patients with uncomplicated acute type B aortic dissection (ATBAD) is unknown. Some studies have noted increased complications, need for early intervention, and mortality with arch involvement. This study aims to determine the impact of arch involvement on outcomes in ATBAD.
METHODS: We reviewed our prospective database of patients admitted with ATBAD from 2000 to 2015. Complications included rupture, clinical malperfusion, refractory pain and hypertension. Neurologic deficits were defined as stroke, paraplegia or paraparesis. Patients with dissection involving the ascending aorta (Stanford Type A) on admission were excluded. Outcomes, including in-hospital morbidity and mortality and need for intervention, were noted. Data were analyzed by standard univariate statistical methods, multiple logistic regression and Kaplan-Meier statistics.
RESULTS: During the study period, 531 patients with ATBAD were admitted, of which 58.7% were uncomplicated ATBAD (uATBAD) and 41.3% were complicated ATBAD (cATBAD). The average age was 60.8 years (64% male) with a median follow up time of 4 years. Arch involvement was present in 176 (33%) patients with ATBAD and was associated with increased admission stroke (p=0.009; OR 10.23) and rupture (p=0.037; OR 2.25). Arch involvement in ATBAD did not impact long-term survival compared to non-arch patients (p=0.21). When stratified for cATBAD, arch involvement again did not demonstrate a significant difference (p= 0.156). The adjusted predictors of long-term mortality in ATBAD include low glomerular filtration rate (GFR) on admission (p=0.005; HR 1.66), age (p=0.007; HR 1.017) and cATBAD (p<0.0001; HR 2.204). After adjustment for cATBAD, admission GFR, and open surgical repair, arch involvement remains a predictor of major respiratory complications (p= 0.0003; OR 2.113) and neurologic deficits (p=0.0178; OR 1.94). However, after adjustment for cATBAD, GFR, and open repair, arch involvement was not associated with early mortality (p=0.18; OR 0.8-3.53). Arch involvement was also not associated with connective tissue disorder (p=0.854) or retrograde dissection (p=0.175).
CONCLUSIONS: Patients with ATBAD and aortic arch involvement are at increased risk of early neurologic and respiratory complications. Arch involvement does not affect short- or long-term survival. Arch involvement in ATBAD does not appear to necessitate a change in management.
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