The clinical profiles and outcomes of acute aortic dissection (AAD) have not been evaluated in China. We retrospectively analyzed, from January 1, 2008 to December 31, 2011, the data from 1,812 patients (mean age 51.1 ± 10.9 years; 77.5% men) with AAD (726 with type A and 1,086 with type B) from 19 large hospitals. Most patients had hypertension and presented with an abrupt onset of chest and/or back pain. Patients with type A AAD were more likely to present with typical symptoms and signs. Computed tomography was the most common initial imaging modality, used in 76.3% of patients with an AAD. The overall in-hospital mortality rate was 17.7%, with most of the deaths occurring within the first week. Surgery was used in 75.3% of patients with type A AAD. The mortality in this cohort was 33.8%. Endovascular treatment was performed in 76.1% of patients with type B AAD. The mortality rate was 2.2%. Multivariate analysis showed that hypertension (odds ratio 2.80, p <0.001), Marfan syndrome (odds ratio 1.76, p = 0.017), anterior chest pain (odds ratio 1.62, p = 0.004), abdominal pain (odds ratio 1.51, p = 0.041), migrating pain (odds ratio 1.56, p = 0.04), and arch vessel involvement (odds ratio 1.70, p <0.001) were predictive factors for increased in-hospital mortality in patients with an AAD. In conclusion, our study has provided insight into the current profiles and outcomes of AAD in China. This knowledge might be useful for clinicians when diagnosing and treating these patients.
Acute aortic dissection (AAD) is a challenging clinical emergency with high morbidity and mortality. To assess the clinical manifestation, diagnosis, management, and outcomes of patients with AAD, the International Registry of Acute Aortic Dissection (IRAD) was established in 1996 and has grown to include approximately 2,000 patients from 26 large referral centers to date. These data from the IRAD were helpful in improving the diagnosis and management of AAD. Most patients in the IRAD are whites from developed countries with advanced medical care; however, the proportion of Asians is very low. The data from the IRAD do not reflect the current reality of Chinese patients with AAD. Although the clinical features of AAD have been reported from some single centers in China, these data might not necessarily be applicable to the general population owing to the small sample size of a single center. The aim of the present study was to analyze the clinical characteristics, management, and outcomes of AAD in China, with the mission of achieving possible improvements in its diagnosis and treatment.
Methods
We retrospectively collected the data from 1,812 patients with AAD from 19 hospitals in China, based on the geographic location (1 in the northeast, 5 in the southeast, 7 in the midland, 3 in northwest, and 3 in southwest) from January 1, 2008 to December 31, 2011, annual outpatient/emergency volume (>200,000 patients), and size (>1,000 beds). The diagnosis was determined from the history, physical examination, imaging, and visualization findings at the surgery or postmortem examination. According to the Stanford classification system, the dissections were divided into 2 categories: those involving the ascending aorta (type A dissection) and those not involving the ascending aorta (type B dissection). The acute stage was confined to the initial 14 days after symptom onset. The patient data were collected using a standard questionnaire developed by principal investigators. The clinical variables included patient demographics, clinical symptoms and signs, imaging findings, management, outcomes, and cause of death. The clinical trial registration number was NCT01552720 .
The data are presented as the mean ± SD for continuous variables and as frequencies and percentages for categorical variables. The continuous variables were compared using the Student t test for normal distributions and the Mann-Whitney U test for non-normal distributions. The categorical variables were evaluated using the Pearson chi-square test or Fisher’s exact test. Survival curves were plotted using the Kaplan-Meier method. Multivariate analysis of the potential risk factors for death was performed using a Cox proportional hazards model. The data analysis was performed using SPSS, version 18.0, statistical analysis software (SPSS, Chicago, Illinois). A p value <0.05 was considered statistically significant.
Results
Of 1,812 patients with an AAD, 726 were diagnosed with type A AAD and 1,086 with type B AAD. The demographic data and patient history are listed in Table 1 . The mean age was 51.1 ± 10.9 years, and the male/female ratio was approximately 3.44:1. Compared to the patients with type B AAD, those with type A AAD were somewhat younger and more were men. Moreover, Marfan syndrome and bicuspid aortic valve were more common in patients with type A AAD, and hypertension, arteriosclerosis, and tobacco use were more frequent in the patients with type B AAD.
| Variable | Total (n = 1,812) | Dissection Type | p Value | |
|---|---|---|---|---|
| A (n = 726) | B (n = 1,086) | |||
| Age | ||||
| Mean ± SD (years) | 51.1 ± 10.9 | 47.5 ± 11.2 | 53.3 ± 10.1 | <0.001 |
| ≥70 (n) | 92 (5.1%) | 22 (3.0%) | 70 (6.4%) | 0.001 |
| 60–69 (n) | 316 (17.4%) | 86 (11.8%) | 230 (21.2%) | <0.001 |
| 50–59 (n) | 584 (32.2%) | 192 (26.4%) | 392 (36.1%) | <0.001 |
| 40–49 (n) | 574 (31.7%) | 252 (34.7%) | 322 (29.7%) | 0.023 |
| <40 (n) | 246 (13.6%) | 174 (24.0%) | 72 (6.6%) | <0.001 |
| Men | 1,404 (77.5%) | 608 (83.7%) | 796 (73.3%) | <0.001 |
| Ethnicity | ||||
| Han | 1,647 (90.0%) | 665 (91.6%) | 982 (90.4%) | 0.395 |
| Hui | 107 (5.9%) | 44 (6.1%) | 63 (5.8%) | 0.818 |
| Meng | 39 (2.2%) | 11 (1.5%) | 28 (2.6%) | 0.126 |
| Other | 13 (0.7%) | 6 (0.8%) | 7 (0.6%) | 0.653 |
| Cause and patient history | ||||
| Hypertension | 1,375 (75.9%) | 532 (73.6%) | 843 (77.6%) | 0.034 |
| Arteriosclerosis | 203 (11.2%) | 64 (8.8%) | 139 (12.8%) | 0.008 |
| Marfan syndrome | 70 (3.9%) | 50 (6.9%) | 20 (1.8%) | <0.001 |
| Coronary heart disease | 63 (1.8%) | 30 (4.1%) | 33 (3.0%) | 0.213 |
| Bicuspid aortic valve | 49 (2.7%) | 39 (5.4%) | 10 (0.9%) | <0.001 |
| Smoke | 859 (47.4%) | 321 (44.2%) | 538 (49.5%) | 0.026 |
| Pregnancy | 2 (0.1%) | 2 (0.3%) | 0 (0.0%) | 0.084 |
| Chronic obstructive pulmonary disease | 14 (0.8%) | 6 (0.8%) | 8 (0.7%) | 0.831 |
| Diabetes mellitus | 32 (1.8%) | 9 (1.2%) | 23 (2.1%) | 0.164 |
| Previous dissection | 48 (2.6%) | 21 (2.9%) | 27 (2.5%) | 0.598 |
| Previous aneurysm | 75 (4.1%) | 27 (3.7%) | 48 (4.4%) | 0.463 |
| Iatrogenic dissection | 67 (3.7%) | 32 (4.4%) | 35 (3.2%) | 0.19 |
| Aortic surgery | 32 (1.8%) | 11 (1.5%) | 21 (1.9%) | 0.507 |
| Aortic valve replacement | 10 (0.6%) | 7 (1.0%) | 3 (0.3%) | 0.053 |
| Coronary artery bypass grafting | 7 (0.4%) | 5 (0.7%) | 2 (0.2%) | 0.09 |
| Endovascular stent grafting | 18 (1.0%) | 9 (1.2%) | 9 (0.8%) | 0.387 |
Chest or back pain was a common presenting symptom ( Table 2 ). Patients with type A AAD were more likely to present with anterior chest pain with an abrupt onset and migrating nature. The pain in patients with type B AAD was mainly located in the back and abdomen. Except for neurologic deficits, the patients with type A AAD were more likely to present with typical physical findings, such as syncope, aortic regurgitation murmur, pulse deficit, shock, and heart failure. The mean systolic blood pressure and diastolic blood pressure tended to be greater in patients with type B AAD compared to those with type A AAD.
| Variable | Total (n = 1,812) | Dissection Type | p Value | |
|---|---|---|---|---|
| A (n = 726) | B (n = 1,086) | |||
| Symptoms and signs | ||||
| Pain | 1,597 (88.1%) | 649 (89.4%) | 948 (87.3%) | 0.192 |
| Anterior chest pain | 1,257 (69.4%) | 554 (76.3%) | 703 (64.7%) | <0.001 |
| Back pain | 1,250 (69.1%) | 450 (62.0%) | 800 (73.8%) | <0.001 |
| Abdominal pain | 222 (12.3%) | 68 (9.4%) | 154 (14.2%) | 0.002 |
| Leg pain | 30 (1.7%) | 8 (1.1%) | 22 (2.0%) | 0.131 |
| Abrupt onset | 1,274 (70.3%) | 541 (74.5%) | 733 (67.5%) | 0.001 |
| Migrating pain | 158 (8.7%) | 89 (12.3%) | 69 (6.4%) | <0.001 |
| Syncope | 104 (5.7%) | 71 (9.8%) | 33 (3.0%) | <0.001 |
| Shock | 91 (5.2%) | 65 (9.0%) | 26 (2.4%) | <0.001 |
| Aortic regurgitation murmur | 167 (9.2%) | 108 (14.9%) | 59 (5.4%) | <0.001 |
| Heart failure | 74 (4.1%) | 40 (5.5%) | 34 (3.1%) | 0.012 |
| Pulse deficit | 256 (14.1%) | 153 (21.1%) | 103 (9.5%) | <0.001 |
| Stroke | 90 (5.0%) | 44 (6.1%) | 46 (4.2%) | 0.081 |
| Other neurologic deficits | 28 (1.5%) | 11 (1.5%) | 17 (1.6%) | 0.928 |
| Systolic blood pressure (mm Hg) | 143.2 ± 24.4 | 136.6 ± 25.5 | 147.6 ± 22.6 | <0.001 |
| Diastolic blood pressure (mm Hg) | 81.8 ± 13.8 | 78.0 ± 15.2 | 84.4 ± 12.0 | <0.001 |
| Diagnostic imaging results | ||||
| Computed tomography | 1,382 (76.3%) | 548 (75.5%) | 834 (76.8%) | 0.52 |
| Transthoracic echocardiography | 1,112 (61.4%) | 446 (61.4%) | 666 (61.3%) | 0.964 |
| Magnetic resonance imaging | 574 (31.7%) | 233 (32.1%) | 341 (31.4%) | 0.756 |
| Aortography | 542 (29.9%) | 209 (28.8%) | 333 (30.7%) | 0.392 |
| Chest radiography | 1,203 (66.4%) | 480 (66.1%) | 723 (66.6%) | 0.306 |
| Normal | 402 (22.2%) | 155 (21.3%) | 247 (22.7%) | 0.484 |
| Mediastinal widening | 432 (23.8%) | 180 (24.8) | 252 (23.2%) | 0.437 |
| Abnormal aortic contour | 208 (11.5%) | 94 (12.9%) | 114 (10.5%) | 0.109 |
| Pleural effusion | 358 (20.0%) | 119 (17.0%) | 239 (22.0%) | 0.01 |
| Electrocardiogram | 1,022 (56.4%) | 440 (60.6%) | 582 (53.6%) | 0.003 |
| Normal | 312 (17.2%) | 119 (16.4%) | 193 (17.8%) | 0.446 |
| Myocardial ischemia | 228 (12.6%) | 137 (18.9%) | 91 (8.4%) | <0.001 |
| Myocardial infarction | 136 (7.5%) | 87 (12.8) | 49 (4.5%) | <0.001 |
| Left ventricular hypertrophy | 248 (13.7%) | 89 (12.3%) | 159 (14.6%) | 0.148 |
| Findings on diagnostic imaging | ||||
| Arch vessel involvement | 516 (28.5%) | 291 (40.1%) | 225 (20.7%) | <0.001 |
| True intramural hemorrhage | 86 (4.7%) | 21 (2.9%) | 65 (6.0%) | 0.002 |
| Periaortic hematoma | 214 (11.8%) | 94 (12.9%) | 120 (11.0%) | 0.22 |
| False lumen thrombosis | 370 (20.4%) | 152 (20.9%) | 218 (20.1%) | 0.655 |
| Aortic regurgitation requiring aortic valve replacement | 209 (11.5%) | 142 (19.6%) | 67 (6.2%) | <0.001 |
| Pericardial effusion | 320 (17.7%) | 164 (22.6%) | 156 (14.4%) | <0.001 |
Multiple imaging tests were performed in 70% of patients with AAD. Computed tomography was the most common initial diagnostic imaging modality and was used in 76.3% of patients with AAD. The choice of imaging modality was not different between those with type A and type B AAD. The diagnostic imaging results showed that true intramural hemorrhage and pleural effusion were more frequent in patients with type B AAD. The patients with type A AAD presented with a greater incidence of myocardial ischemia/infarction, arch vessel involvement, aortic regurgitation, and pericardial effusion than the patients with type B AAD.
Surgery was preformed in 547 patients with type A AAD to replace the affected ascending aorta with or without the aortic arch (67%) or because of involvement of the aortic valve or ostia of the coronary arteries (28%) or because of Marfan syndrome (5%). Among the patients with type B AAD, surgical intervention was indicated for intractable pain in 12, uncontrolled hypertension in 9, impending aortic rupture in 11, extension of the dissection in 5, and malperfusion syndrome in 7 patients. Endovascular treatment was used in 52 patients with type A AAD and 826 with type B AAD, in whom the entry tear was located in the descending aorta or distal aortic arch. Hybrid procedures, combined with surgical great vessel bypass with endovascular stent graft implantation, were performed as a single step (25%) or in 2 steps (75%) in 32 patients type A AAD. The reason for medical management for 311 patients with AAD included older age (16%), intramural hematoma (18%), refusal of surgery and endovascular treatment by patients and/or family (36%), and the presence of significant co-morbid conditions in the remaining.
Except for endoleak, which occurred more commonly in patients with type B AAD, the in-hospital complications were more frequent in patients with type A AAD. Significant differences were found between those with type A AAD and type B AAD. The overall in-hospital mortality rate was 17.7%. Approximately 80.0% of the in-hospital deaths occurred in the first week. The causes of in-hospital death included aortic rupture in 85.1%, shock in 6.9%, neurologic complications in 4.3%, and myocardial ischemia/infarction in 3.7%. Patients with type A AAD who underwent medical management had the greatest mortality ( Table 3 and Figure 1 ). Furthermore, the mortality rate was lowest in those with type B AAD who underwent endovascular treatment ( Table 3 and Figure 2 ). Multivariate analysis showed that hypertension, Marfan syndrome, anterior chest pain, abdominal pain, migrating pain, and arch vessel involvement were independent predictors of increased in-hospital mortality for patients with AAD ( Table 4 ).
| Variable | Total (n = 1,812) | Dissection Type | p Value | |
|---|---|---|---|---|
| A (n = 726) | B (n = 1,086) | |||
| Treatment | ||||
| Medical treatment | 311 (17.2%) | 117 (16.1%) | 194 (17.9%) | <0.001 ⁎ |
| Surgery | 591 (32.6%) | 547 (75.3%) | 44 (4.1%) | |
| Endovascular treatment | 878 (48.5%) | 52 (7.2) | 826 (76.1%) | |
| Hybrid treatment | 32 (1.8%) | 10 (1.4%) | 22 (2.0%) | |
| In-hospital complications | ||||
| Coma | 130 (7.2%) | 96 (13.2%) | 34 (3.1%) | <0.001 |
| Acute renal failure | 121 (6.7%) | 76 (10.5%) | 45 (4.1%) | <0.001 |
| Shock | 101 (5.6%) | 87 (11.9%) | 14 (1.3%) | <0.001 |
| Myocardial ischemia/infarction | 63 (3.5%) | 55 (7.6%) | 8 (0.7%) | <0.001 |
| New neurologic deficits | 84 (4.6%) | 63 (8.7%) | 21 (1.9%) | <0.001 |
| Endoleak | 133 (7.3%) | 8 (1.1%) | 125 (11.5%) | <0.001 |
| In-hospital mortality | ||||
| Overall mortality | 321 (17.7%) | 248 (34.2%) | 73 (6.7%) | <0.001 |
| Mortality of medical treatment | 89 (28.6%) | 51 (43.6%) | 38 (19.6%) | <0.001 |
| Mortality of surgical treatment | 198 (33.5%) | 185 (33.8%) | 13 (29.5%) | 0.037 |
| Mortality of endovascular treatment | 28 (5.8%) | 10 (19.2%) | 18 (2.2%) | <0.001 |
| Mortality of hybrid treatment | 5 (15.6%) | 2 (20.0%) | 3 (13.6%) | 0.903 |
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