| BackgroundsAortic dissection(AD)is a challenging clinical emergency,which refers to an injury to the innermost layer of the aorta allows blood to flow between the layers of the aortic wall,forcing the layers apart,resulting in a pathological state of true and false aortic lumen.It is characterized by rapid onset,diverse clinical manifestations,complex pathophysiological processes and high early mortality.The overall mortality rate of untreated AD patients is about 40%,and despite receiving in-hospital treatment,there is still a 5-20%mortality rate during hospitalization.After active treatment,the overall survival rate of Stanford B-type AD was more than 90%in 30 days.Therefore,early diagnosis and treatment is particularly important for improving the prognosis of Stanford B-type AD patients.The 2010 American Heart Association(ACC)Guidelines for the Diagnosis and Treatment of Aortic Diseases(AD)pointed out that endothoracic aortic repair(TEVAR)should be performed as soon as possible in Stanford B AD patients with high-risk clinical manifestations such as intractable pain,uncontrollable hypertension,poor organ perfusion or aortic rupture.Patients without the above manifestations are advised to best medical therapy.However,many clinical studies have found that up to 20%to 50%of patients eventually need interventional or surgical intervention because of dissecting aneurysm or convert to complicated clinical manifestations.In addition,the aortic remodeling was not good after TEVAR in chronic phase.Therefore,several studies showed early TEVAR can significantly reduce long-term adverse aortic events in uncomplicated Stanford B type AD patients without the above-mentioned high-risk clinical manifestations compared with drug therapy alone.Meanwhile,the recommended level of TEVAR for these patients in the 2014 European Heart Association(ESC)guidelines for aortic diagnosis and treatment is Grade IIA and Grade B evidence.However,the guidelines do not specify whether all uncomplicated Stanford B-type AD patients benefit from early TEVAR.Moreover,there is still a lack of relevant research on prognostic factors of TEVAR in these patients.PurposeThis study analyzed the efficacy and prognosis of endovascular thoracic aortic repair for uncomplicated Stanford B-type AD,established a risk prediction model for adverse aortic events,stratified the risk of patients,and formulated individualized treatment strategies to improve outcome.MethodsA total of 522 patients with uncomplicated Stanford B type AD who underwent TEVAR in the Department of Cardiology,Guangdong Provincial People's Hospital from January 2010 to December 2017 were selected retrospectively.The baseline data,operation-related information and CTA imaging data of aorta were collected.All Follow-up data was obtained by outpatient,telephone and inpatient review in October 2018.Multivariate Cox regression model was established to analyze independent predictors of adverse aortic events in uncomplicated Stanford B-type AD patients after TEVAR.ResultsBased on Kaplan-Meier survival analysis,the 1-year overall survival rate was 97.3%,the 1-year free of adverse aortic events survival rate was 96.7%,the 5-year overall survival rate was 89.0%,and the 5-year free of adverse aortic events survival rate was 84.8%.Cox regression model was established for multiple factors of adverse aortic events.Comorbid with chronic renal disease(HR=4.688;95%CI=1.936-11.356;P=0.001)was independent predictors of adverse aortic events in Patients with uncomplicated Stanford type B AD after TEVAR.Other predictors included grade 3 hypertension(HRF=2.856;95%CI=1.250-6.527;P=0.013),ascending aorta width>40 mm(HR=2.972;95%CI=1.514-5.834;P=0.002)and implantation of two or more covered stents(HRF=2.307;95%CI=1.135-4.689;P=0.021).Compared with preforming TEVAR in 7 days after onset of AD,TEVAR in 8-14 days was the protective factor(HRL=0.373;95%CI=0.165-0.842;P=0.018).The prevalence of aortic adverse events was 3.1%(3/96)in patients without any independent predictors;6.8%(14/206)in patients with only one independent predictor;16.8%(27/161)in patients with two independent predictors;27.1%(13/48)in patients with three independent predictors and 54.5%(6/11)in patients with four independent predictors.With the increase of the number of independent predictors,the incidence of adverse aortic events in uncomplicated Stanford B patients significantly increased af:ter TEVAR(P<0.001;linear trend test P<0.001).ConclusionsChronic renal disease were independent predictors of adverse aortic.events in patients with uncomplicated Stanford B-type AD after TEVAR.Other independent predictors included grade 3 hypertension,ascending aorta width>40 mm,and implantation of two or more covered stents.Compared with TEVAR in 7 days after onset of AD,TEVAR in 8-14 days was the protective factor.With the increase of the number of combined predictors,the incidence of adverse aortic events significantly increased.For uncomplicated Stanford B-type AD patients with the above predictors,more close surveillance is required after TEVAR,especially those with two or more predictors. |
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