| Part I: Analysis of basic clinical features and their trends in patients with acute aortic dissection during ten years Objective: Under the aging process of the Chinese population,we expect to further elucidate the epidemiological characteristics and their trends of Chinese AAD patients by retrospectively analyzing the clinical data of AAD patients in our center during 10 years and comparing it with related studies in China and abroad.Methods: The clinical data of AAD patients in our center from 2011 to 2020 were retrospectively collected,including gender,age,household registration,ABO blood type,previous medical history,initial symptoms,the time interval from onset to admission,and diagnosis method.AAD involving the ascending aorta was defined as ATAAD,and AAD not involving the ascending aorta was defined as ATBAD.Results: A total of 2719 patients with AAD were included in this study,and the number of patients with AAD increased linearly over 10 years.Among all AAD patients,there were1337 ATAAD patients,accounting for 49.2%,and the percentage of ATAAD patients showed a decreasing trend during the 10 years.There were 2205 male patients,accounting for 81.1%,and the proportion of male patients fluctuated less during the 10 years.The mean age of all AAD patients was 52.6 ± 11.3 years,and the mean age of AAD patients increased linearly over 10 years.Meantime,the age distribution of AAD patients changed significantly during the 10 years: the number of patients aged 51-60 years,61-70 years and over 70 years were increasing,and the number of patients under 50 years was decreasing.Hypertension was the most common comorbidity among all AAD patients,accounting for 56.1%,and the proportion of patients with AAD combined with hypertension was gradually increasing during the 10 years.In terms of clinical presentation at admission,the most common symptom was chest pain,followed by back pain.The median time from onset to admission was 12 hours for all patients with AAD,and 74.9% of patients were admitted within 1 day,with the median time from onset to admission gradually decreasing over the 10 years.CTA was the most common diagnostic method for all patients.The proportion of patients who completed CTA examination in our center on admission was 87.2%,and the proportion gradually increased during the 10 years.Conclusions: Likely,China is currently experiencing an increase in the incidence of AAD,and domestic cardiovascular centers will face more elderly AAD patients under the background of population aging.In view of the epidemiological characteristics of early age of onset and high male predominance of AAD patients,the control of AAD-related risk factors needs to be further strengthened in the future.Part II: Analysis of management strategies and clinical outcomes and their trends of patients with acute aortic dissection during ten yearsObjective: To explore trends in treatment and outcomes of single-center AAD patients under management practice updates by retrospectively analyzing the treatment methods,hospital outcomes and mid-term follow-up survival of AAD patients in our center during the 10 years.Methods: The clinical data of AAD patients in our center,including treatment modalities,in-hospital mortality,and deaths during mid-term follow-up,was retrospectively collected from 2011-2020.The data was analyzed after dividing the study time into 5 phases: 2011-2012,2013-2014,2015-2016,2017-2018 and 2019-2020.The start of follow-up began after discharge,with an overall follow-up rate of 80.5% and a follow-up time of 3.3 ± 2.4 years.AAD involving the ascending aorta was defined as ATAAD,and AAD not involving the ascending aorta was defined as ATBAD.Results: A total of 2719 AAD patients were included,including 1337 ATAAD patients and 1382 ATBAD patients.During 10 years,the main treatment for patients with ATAAD was surgery,followed by medical treatment.The proportion of surgical treatment was maintained at about 60% after the first stage of decline.The proportion of medical treatment increased to 29% in the early stage and then gradually decreased.During 10 years,after the "0" breakthrough was achieved in the early stage of hybrid repair and endovascular repair,the overall proportion maintained an upward trend.The in-hospital mortality of ATAAD patients who received surgery during the 10 years increased from 20.3% in the early stage to 26.9% in the middle stage,and then gradually decreased to 17.6% in the current stage.The 1-year,5-year and 8-year survival rate after discharge was 90.8%,82.7% and 78.2% respectively.The in-hospital mortality of ATAAD patients who received medical treatment during the 10 years decreased from 68.4% in the early stage to 33.3% in the current stage,and the half-year,1-year and 3-year survival rate was 26.1%,23.5% and 21.9%,respectively.During the 10 years,the main treatment for ATBAD patients was endovascular repair,accounting for 79.7%,followed by medical treatment,accounting for 13.4%.The proportion of endovascular repair maintained a steady upward trend after a substantial increase in the early stage,and was about 85% in recent years.The proportion of medical treatment showed the opposite trend,which has dropped from 33.3%in the early stage to about 10% at present.In-hospital mortality of ATBAD patients undergoing endovascular repair increased slightly in the early stage with a small number of patients,and is currently stable at about 1.5%.However,the in-hospital mortality of ATBAD patients who received medical treatment fluctuated greatly in the early stage,up to 21.7%,and stabilized at about 10% in the subsequent stages.The 1-,5-,and 8-year survival rate of ATBAD patients who received endovascular repair were 96.7%,90.1%,and 85.4%,respectively,while the 1-,5-,and 8-year survival rate of ATBAD patients who received medical treatment was 84.2%,68.4%,and 53.9%,respectively,and the difference was statistically significant.Conclusions: The improvement of surgical outcomes and the progress of hybrid technology and endovascular repair in ATAAD patients are the manifestation of our center’s improved diagnosis and treatment capability over the 10 years,while the gradual decrease in in-hospital mortality in ATBAD patients is attributed to the rapid development of endovascular repair.But,the high proportion of domestic ATAAD patients receiving medical treatment is a detrimental factor affecting the overall survival of ATAAD patients in China compared to that in western developed countries.Part III: TEC aortic dissection classification based on the extent of dissection involvement,primary entry location and emergency intervention signalsObjective: Both the Stanford classification and the De Bakey classification were created in the 1960 s based on the anatomical and pathological characteristics of less than 50 patients.At present,they cannot be well matched with the current clinical management practice of AD.This study proposes a AD classification based on the extent of dissection,the location of the primary entry,and related emergency intervention signals,and uses the clinical data of our center to preliminarily verify the rationality of this classification.Methods: Based on the Stanford classification,the dissection involving the aortic arch but not the ascending aorta was separated from the current definition of TBAD and defined as type non-A non-B AD.The location of the primary entry on CTA was indicated as "1","2" and "3" for the ascending aorta,aortic arch,and descending aorta,respectively;if the location of the primary entry on CTA could not be identified,it was indicated as "0".MPS and rupture as a complex feature of all AD patients and pericardial tamponade as an additional complex feature of TAAD patients were included.The AD classification consists of these three elements,referred to as the TEC(type,entry,and complication)classification.In the validation phase,a total of 2369 AD patients with complete CTA images at admission from 2011 to 2020 were included to validate the classification in terms of the prognosis of patients with non-A non-B AD,the outcome of TAAD patients with primary rupture location in the descending aortic and aortic arch who underwent endovascular repair,and the risk factors for in-hospital mortality in AD patients.Results: In this study,there were 160 non-A non-B AD patients,accounting for 6.8%.After admission,60.0% of patients underwent endovascular repair;24.4% underwent hybrid repair;and the number of patients who underwent surgery was the smallest,only 3.The in-hospital mortality of non-A non-B AD patients receiving non-medical treatment was 3.6%,while the in-hospital mortality rate of medical treatment was 9.1%,and the difference was not statistically significant.The 1-,5-,and 8-year survival rate of non-A non-B AD patients undergoing non-medical treatment was 92.7%,86.0%,and 86.0%,respectively,while the 1-,5-,and 8-year survival rates of medically treated patients were 68.8%,68.8%,and 55.0%,respectively,and the difference in survival was statistically significant.Non-A non-B AD patients require more additional operations such as fenestration,branch stents,left subclavian artery closure,and bare stent modification during endovascular repair than TBAD patients,and after endovascular repair,the proportion of endoleak and retrograde TAAD was also higher than that of TBAD patients,and the difference was statistically significant.In this study,52 patients with TAAD whose primary entry was in the descending aorta or aortic arch underwent endovascular repair,with 4 in-hospital deaths,and 1-and 5-year survival rate was 91.9% and 91.9%,respectively.Regarding risk factors for in-hospital death in AD,preoperative MPS was an independent preoperative risk factor for in-hospital death after surgery in TAAD patients,whereas pericardial tamponade and rupture were independent risk factors for in-hospital death in TAAD patients treated medically.Similarly,rupture and MPS were the more direct risk in the investigation of causes of in-hospital death in TBAD patient.Conclusions: TEC classification is a consolidation and refinement of several currently published AD classification,including key information about management and prognosis of AD and facilitating the rapid assessment of the risk of AD by non-cardiologists when making a diagnosis. |
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