Society For Clinical Vascular Surgery

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Cocaine Abuse is Associated with Worse Outcomes after TEVAR in Patients with Type B Aortic Dissections
Daniel Krcelic, MD, Halim Yammine, MD, Jocelyn K. Ballast, BA, William E. Anderson, MS, Tzvi Nussbaum, MD, Charles S. Briggs, MD, Gregory A. Stanley, MD, John R. Frederick, MD, Frank R. Arko, III, MD.
Carolinas Medical Center, Charlotte, NC, USA.

OBJECTIVES: To describe the initial presentation of TBAD patients with and without cocaine abuse and compare their outcomes after TEVAR.
METHODS: Cocaine use was noted in 14 of 186 patients who underwent TEVAR for TBAD between January 2012 and January 2017. Data were collected under an IRB-approved protocol. Survival, reintervention, complications, and characteristics of dissection were compared between patients with (C+, n=14) and without (C-, n=172) cocaine use using Kaplan-Meier analysis, Fisher’s exact test, and the Wilcoxon rank sum test.
RESULTS: Cocaine users were more frequently African American (86%C+, 40%C-, p=.008), on Medicaid (54%C+, 13%C-, p=.0008), smokers (79%C+, 47%C-, p=.02), and had a higher frequency of alcohol abuse (29%C+, 5%C-, p=.007). They were also significantly younger (52.6(7.4)C+, 62.4(13.7)C-, p=.004), and more frequently males (71%C+, 59%C-, p=.4). All the C+ patients had hypertension, as did 92% of C- (p=.6). Cocaine abusers had larger aortic diameters (mm) just distal to the LSA and at the proximal landing zone, as well as larger false lumen sizes just distal to the LSA, at the carina, and at the largest point of dissection (Table 1). C+ had higher diastolic pressures at discharge and at 30 days (p=.03 and p=.05). Kaplan-Meier survival estimates found 30-day and 1-year survival rates of 93% and 73% for C+ patients and 93% and 84% for C-, but no significant differences between the groups’ survival curves (p=.9). However, Kaplan-Meier survival estimates found that cocaine abusers had a shorter time to aortic re-intervention (p=.04) and more reinterventions (0.8(0.9)C+, 0.4(0.7)C-, p=.009). C+ patients also had more endoleaks (57%C+, 21%C-, p=.005).
CONCLUSIONS: Cocaine users in our study were more likely to be young African American males who smoked. They tended to present with worse dissections. They had higher incidences of endoleaks and reinterventions, and while the numbers are small, 1 year mortality appears to be higher. This is a complex subset of patients with aortic dissections who may require aggressive social interventions in addition to TEVAR to prevent complications arising from continued cocaine abuse and possibly improve long-term outcomes.

Table 1. Diameters (mm) at presentation. Results displayed as mean (SD).
Diameter of the:Cocaine (n=14)No Cocaine (n=172)p-value
Aorta just distal to the LSA35.5 (6.0)31.0 (5.9)0.004
False Lumen just distal to the LSA7.6 (11.4)1.8 (4.5)0.02
Aorta at the Carina43.0 (12.2)37.6 (10.0)0.1
True Lumen at the Carina17.1 (7.8)21.7 (9.0)0.06
False Lumen at the Carina27.5 (15.2)16.1 (13.1)0.02
Aorta at the Largest point of dissection44.8 (8.7)42.8 (13.1)0.3
True Lumen at the largest point of dissection17.2 (7.0)20.7 (10.0)0.2
False Lumen at the largest point of dissection29.7 (13.3)20.5 (10.7)0.03
Proximal Neck33.6 (3.5)30.2 (4.2)0.004

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