and Outcomes in Patients With Uncomplicated Type B Aortic Dissection [PDF]

SLIDE 1

emoryhealthcare.org/vascular

1

emoryhealthcare.org/vascular

Racial Differences In Patterns of Presentation and Outcomes in Patients With Uncomplicated Type B Aortic Dissection

Matthew Aizpuru BA1, Xiaoying Lou MD2, Jaime Benarroch-Gampel MD1, William D Jordan Jr. MD1, Bradley G Leshnower MD2, & Robert S Crawford MD1

Emory University School of Medicine Department of Surgery Division of Vascular Surgery1 and Division of Cardiothoracic Surgery2 Atlanta, Georgia

SLIDE 2

emoryhealthcare.org/vascular

2

DISCLOSURES

The speaker has no financial or other

conflicts of interest to disclose.

SLIDE 3

emoryhealthcare.org/vascular

3

INTRODUCTION

Aortic Dissection is a common vascular emergency

(3-4 cases per 100,000 people per year)

The current treatment for uncomplicated type B

aortic dissection is medical management, however

utcomes remain poor overall.

SLIDE 4

emoryhealthcare.org/vascular

4

TEVAR VS MEDICAL MANAGEMENT

Data from Emory University,

Division of Cardiothoracic Surgery

Trend towards improved mortality

for TEVAR up front vs. medical management (84% vs 59%, p=.17)

SLIDE 5

emoryhealthcare.org/vascular

5

INTRODUCTION

Racial differences in vascular surgery patients are

well established, with minority races having disparate outcomes.

The data in type B aortic dissection (TBAD) is scarce.

SLIDE 6

emoryhealthcare.org/vascular

6

INTRODUCTION

Administrative database of

TAAD & TBAD

Non-White patients present

younger & more female

No difference in

comorbidities, access to care or mortality

SLIDE 7

emoryhealthcare.org/vascular

7

INTRODUCTION

Multicenter, TAAD & TBAD

(n=189 AA, n=1,165 Wh)

AA present younger
AA have more HTN, T2DM

& cocaine abuse

Mortality similar in-hospital

and up to 3 years

SLIDE 8

emoryhealthcare.org/vascular

8

INTRODUCTION

Single institution
Complicated TBAD
AA present younger & with

worse BP control

White patients have

inferior survival at 5 years

SLIDE 9

emoryhealthcare.org/vascular

9

OBJECTIVE

Describe racial differences in presentation

and outcomes in patients with uncomplicated Type B Aortic Dissection (uTBAD).

SLIDE 10

emoryhealthcare.org/vascular

10

METHODS

Retrospective review of 353 consecutive

patients (227 African American, 126 White) treated for TBAD at Emory.

Analysis focused on 276 (178 African

American, 98 White) uTBAD patients.

Univariate analysis with chi-square and t-

tests.

Kaplan Meier survival analysis

SLIDE 11

emoryhealthcare.org/vascular

11

Factor AA n=178 White n=98 p

Male Gender 114 (64%) 67 (68%) 0.5 Age 55.6 (11.2) 59.3 (12.7) 0.01 Smoking 46 (26%) 22 (22%) 0.5 Diabetes 38 (21%) 6 (6%) <0.01 Hypertension 169 (95%) 87 (89%) 0.06 End Stage Renal Disease 27 (15%) 2 (2%) <0.01 Beta Blocker Use 88 (49%) 50 (51%) 0.9

RESULTS

SLIDE 12

emoryhealthcare.org/vascular

12

Factor AA n=178 White n=98 p

Male Gender 114 (64%) 67 (68%) 0.5 Age 55.6 (11.2) 59.3 (12.7) 0.01 Smoking 46 (26%) 22 (22%) 0.5 Diabetes 38 (21%) 6 (6%) <0.01 Hypertension 169 (95%) 87 (89%) 0.06 End Stage Renal Disease 27 (15%) 2 (2%) <0.01 Beta Blocker Use 88 (49%) 50 (51%) 0.9

RESULTS

SLIDE 13

emoryhealthcare.org/vascular

13

RESULTS: PRESENTATION

Anatomical Factor AA White p

Diameter of Thoracic Aorta (cm)

4.6 4.7 0.2

Diameter of Abdominal Aorta (cm)

3.7 3.6 0.9

Thoracoabdominal Extension

71% 72% 0.8

Patent False Lumen

53% 50% 0.8

SLIDE 14

emoryhealthcare.org/vascular

14

RESULTS: PRESENTATION

Anatomical Factor AA White p

Diameter of Thoracic Aorta (cm)

4.6 4.7 0.2

Diameter of Abdominal Aorta (cm)

3.7 3.6 0.9

Thoracoabdominal Extension

71% 72% 0.8

Patent False Lumen

53% 50% 0.8

Anatomically Similar on Presentation

SLIDE 15

emoryhealthcare.org/vascular

15

Anatomical Factor AA White p

Diameter of Thoracic Aorta (cm)

5.2 5.4 0.3

Growth of Thoracic Aorta (cm/week)

0.06 0.02 0.1

Diameter of Abdominal Aorta (cm)

3.7 3.6 0.6

Growth of Abdominal Aorta (cm/week) -0.01

0.01 0.4

Patent False Lumen

42% 40% 0.8

RESULTS: FOLLOW UP

SLIDE 16

emoryhealthcare.org/vascular

16

Anatomical Factor AA White p

Diameter of Thoracic Aorta (cm)

5.2 5.4 0.3

Growth of Thoracic Aorta (cm/week)

0.06 0.02 0.1

Diameter of Abdominal Aorta (cm)

3.7 3.6 0.6

Growth of Abdominal Aorta (cm/week) -0.01

0.01 0.4

Patent False Lumen

42% 40% 0.8

Anatomically Similar on Follow Up

RESULTS: FOLLOW UP

SLIDE 17

emoryhealthcare.org/vascular

17

Indication for Intervention AA White

Growth/Size

N=60(86%) N=46(84%)

Pain or Malperfusion

N=10(14%) N=9(16%)

RESULTS: MANAGEMENT

No Difference in Indication for Surgery (p=.7)

SLIDE 18

emoryhealthcare.org/vascular

18

RESULTS: MANAGEMENT Definitive Treatment

AA White

Medical Management Only N=108(60%) N=43(44%) Open Repair N=35(20%) N=18(18%) TEVAR/EVAR N=35(20%) N=37 (38%)

SLIDE 19

emoryhealthcare.org/vascular

19

RESULTS: MANAGEMENT Definitive Treatment

AA White

Medical Management Only N=108(60%) N=43(44%) Open Repair N=35(20%) N=18(18%) TEVAR/EVAR N=35(20%) N=37 (38%)

More Interventions for White Pts (p=.004), Predominantly TEVAR/EVAR

SLIDE 20

emoryhealthcare.org/vascular

20

RESULTS: MANAGEMENT Operative Treatment

AA White

Open Repair N=35(50%) N=18(33%) TEVAR/EVAR N=35(50%) N=37 (67%)

SLIDE 21

emoryhealthcare.org/vascular

21

Operative Treatment

AA White

Open Repair N=35(50%) N=18(33%) TEVAR/EVAR N=35(50%) N=37 (67%)

More Open Surgery for AA (p=0.05)

RESULTS: MANAGEMENT

SLIDE 22

emoryhealthcare.org/vascular

22

RESULTS: SURGICAL

Outcome

AA (n=70) White (n=55) p In-Hospital Mortality N=8 (11%) N=3 (5%) 0.2 Major Complication or Death (Sum)* N=18 (26%) N=4 (7%) 0.01 Re-intervention N=14 (20%) N=10 (18%) 0.8

*Major complication defined as stroke, spinal cord ischemia or renal failure

SLIDE 23

emoryhealthcare.org/vascular

23

Outcome

AA (n=70) White (n=55) p In-Hospital Mortality N=8 (11%) N=3 (5%) 0.2 Major Complication or Death (Sum)* N=18 (26%) N=4 (7%) 0.01 Re-intervention N=14 (20%) N=10 (18%) 0.8

*Major complication defined as stroke, spinal cord ischemia or renal failure

Increased Perioperative Morbidity/Mortality for AA

RESULTS: SURGICAL

SLIDE 24

emoryhealthcare.org/vascular

24

RESULTS: KAPLAN MEIER INTERVENTION FREE SURVIVAL

Years After Diagnosis 1 Year 3 Years 5 Years African American Intervention Free Survival 73% 61% 49% Number at Risk 114 74 46 White Intervention Free Survival 71% 43% 32% Number at Risk 65 34 22

Decreased IFS at 5 years for White Pts p=.05 AA Wh

SLIDE 25

emoryhealthcare.org/vascular

25

RESULTS: KAPLAN MEIER ALL CAUSE SURVIVAL

Years After Diagnosis 1 Year 3 Years 5 Years 10 Years African American All Cause Survival 93% 88% 76% 55% Number at Risk 141 103 70 20 White All Cause Survival 89% 78% 71% 45% Number at Risk 79 63 46 16

No difference in survival up to 10 years p=.17 AA Wh

SLIDE 26

emoryhealthcare.org/vascular

26

CONCLUSIONS

African Americans with uTBAD present

younger, with more comorbidities.

African Americans have more open
perations.
These increases in open surgery may be due

to the younger age of African Americans.

AA have more perioperative morbidity &

mortality.

SLIDE 27

emoryhealthcare.org/vascular

27

Differences in intervention free survival

appear to be driven mostly by endovascular interventions

No difference in overall long-term mortality

between AA and White patients with uTBAD

CONCLUSIONS

SLIDE 28

emoryhealthcare.org/vascular 28

Thank You

SLIDE 29

emoryhealthcare.org/vascular 29

INSTEAD TRIAL

The INvestigation of STEnt Grafts in Aortic

Dissection (INSTEAD), 2009

RTC: 140 pts, 2 wks after diagnosis of TBAD.

Medical mgmt vs stent graft + med mgmt.

No difference in all cause survival at 2 years

(96% vs 89%, p=0.15)

INSTEAD XL @ 5 yrs, all cause survival (89%