Trends in the incidence,surgical management and outcomes of type B aortic dissections in Australia over the last decade

Abstract

Objectives

This study aims to investigate the incidence and in-hospital outcomes of surgical repair for type B aortic dissection (TBAD) in Australia.

Methods

Data were obtained from the Australasian Vascular Audit (AVA) and the Australian Institute of Health and Welfare (AIHW). The former is a total practice audit mandated for all members of the Australian and New Zealand Society for Vascular Surgery (ANZSVS) while the latter is an independent government agency which records all healthcare data in Australia. All cases of TBAD which underwent surgical intervention (endovascular or open repair) between 2010 and 2019 were identified using prospectively recorded data from the AVA (New Zealand data was excluded). The primary outcomes were temporal trends in procedures and hospital mortality; secondary outcomes were complications and risk factors for mortality. All admissions and procedures for, and hospital deaths from, TBAD in Australia were identified in AIHW datasets using the relevant diagnosis and procedure codes, with age-standardized rates calculated for the period 2000–01 to 2018–19.

Results

A total of 567 cases of TBAD underwent vascular surgical intervention (AVA data, Australia). Of these, 96.3% were treated by endovascular repair. There was an increase in the annual procedure number from 45 in 2010 to 88 in 2019. In-hospital mortality was 4.8% for endovascular repair and 19% for open repair (p = 0.021). From 2000-01 to 2018-19, the age-standardized procedure rates for TBAD (Australia) doubled, the proportion of admitted patients undergoing a procedure rose from 28% to 43%, and in-hospital deaths fell by 25%.

Conclusion

There has been an increasing incidence of vascular surgical intervention for TBAD in Australia. The majority of patients received endovascular therapy while the mortality from surgically managed TBAD appears to be falling.

Keywords

aortic dissection type B aortic dissection thoracic endovascular aortic repair TEVAR vascular vascular surgery

Background

Type B aortic dissections (TBAD) commence distal to the left subclavian artery origin¹ while the most common predisposing risk factor is uncontrolled hypertension.² Acute TBADs are subdivided into complicated and uncomplicated cases. Complicated dissections are defined as the presence of rapid aortic expansion, aortic rupture and/or hypotension/shock, end organ/limb ischemia, paraplegia/paraparesis, peri-aortic haematoma, recurrent or refractory pain, and refractory hypertension despite adequate medical therapy.² Cases without these sequelae are defined as uncomplicated.

Current Guidelines from the European Society of Vascular Surgery promote medical therapy as the first line treatment in uncomplicated TBAD.³ Best medical therapy typically includes aggressive management of blood pressure, pulse rate and pain.^4,5 A 1-year survival rate of between 80 and 90% can be achieved with this approach.^6,7 However, these short term results do not take into account the late complications of untreated aortic dissection with one study estimating a 5-year mortality rate of 30%.⁵ Based on these observations, more proactive surgical management of these cases has been the subject of recent research.^8-10 In contrast to uncomplicated TBAD, there is no debate that complicated TBAD warrants emergency or urgent surgical management.³ Endovascular intervention far exceeds conventional open surgery as the preferred treatment modality with in-hospital mortality having been shown to be significantly higher after open surgery (33.9% vs. 10.6%).^11,12 Most of the reported evidence originates from high volume centres reporting on selected patient cohorts.¹² Even the International Registry of Acute Aortic Dissections (IRAD) utilizes just 30 referral centres based across 11 countries – a limitation which may result in selection bias.¹³

The current study aims to review the risk factors, surgical approach and in-hospital outcomes following vascular surgical intervention for TBAD over the last decade, based on data from a comprehensive national surgical audit. By including the total practice of all practicing vascular surgeons in the region, it reflects non-selective real life data. In addition, age-standardized temporal trends over the last two decades are reported using data from the Australian national hospital morbidity and mortality datasets.

Materials and methods

Data sources

Demographic and operative data were extracted from the Australasian Vascular Audit (AVA, https://www.ava.net.au/). The AVA is a nationwide, individual, total practice audit mandated for all members of the Australian and New Zealand Society for Vascular Surgery (ANZSVS). Members of the ANZSVS are required to enter their operative activity for all public and private hospitals in which they conduct audited index vascular procedures.¹⁴ It captures five basic risk factors (hypertension, ischaemic heart disease, diabetes, chronic kidney disease (creatinine >150 mol/L) and smoking status), procedure details, length of stay, complications and mortality (but not cause of death) for each hospital admission. However, post-discharge mortality is not documented (inclusive of mortalities at a secondary hospital following transfer post-surgical intervention). Specific in-hospital reportable complications included the following: acute myocardial infarction, arrhythmia, respiratory failure, pneumonia, renal impairment, renal failure, visceral ischaemia, stroke, paraplegia, reactionary haemorrhage and return to theatre. Date of admission and discharge were also recorded, allowing for length of hospital stay to be assessed/calculated.

Definitions and endpoints

All patients with a diagnosis of TBAD (‘dissection’) who underwent vascular surgical intervention in Australia, between 01/01/2010 and 31/12/2019, were identified (AVA data). Cases were classified as either acute or chronic dissections. Procedures were classified as either endovascular repair (TEVAR) or open aortic repair (OAR). Procedures whereby TEVAR was performed with a concomitant carotid-subclavian bypass were included as endovascular repair (TEVAR) within the analysis, as this was deemed to be an adjunct procedure. Cases were excluded; if they were undertaken as part of a hybrid procedure with cardiothoracic involvement (indicative of intervention for type A aortic dissection), if they could not be clearly categorized (due to mixed entries in regards to the open component), or if they were undertaken for the management of blunt traumatic thoracic aortic injury (this was deemed to be a separate pathological process) (see Supplement Table S1). Surgical intervention recorded in the AVA for procedures performed in New Zealand were also excluded to allow comparability between Australian AVA data and the Australian Institute of Health and Welfare (AIHW) data. Outcomes were assessed according to type of surgery (TEVAR vs OAR), categorization of dissection (acute vs chronic), and urgency of intervention (emergency, semi-urgent, elective) utilizing the AVA data.

The AIHW (aihw.gov.au) is an independent government agency which records a wide range of healthcare data in Australia. In order to assess the temporal trends in total (including non-operative cases) hospital admissions and deaths, additional national (Australia only) age-standardized rates of admissions, procedures and in-hospital deaths from the AIHW for the period 2000–2001 to 2018–2019 were obtained. Cases were identified by using the International Classification of Diseases Australian Modification code I71.01 and relevant Procedure codes (as outlined in Supplementary Table S2).

Statistical analyses

Numeric data were expressed as means and standard deviations (SD) or median and range, as appropriate. Categorical variables were compared between groups using Chi Square and Fisher exact tests, and continuous variables were compared using analysis of variance. Logistic regression modelling was used to examine the association between patient variables and in-hospital mortality. A p value of <0.05 was considered statistically significant. Analyses were performed utilizing SAS software (version 9.4; SAS Institute, Cary, NC, USA).

Results

Patient characteristics, comorbidities and interventions (AVA data)

Data extraction from the AVA identified 650 cases which underwent vascular surgical intervention for ‘dissection’ in Australia. This was further examined, as per the criteria outlined in the methodology, with 83 cases excluded (Figure 1, see Supplement Table S1) leaving a total of 567 cases. The baseline demographics and procedure types of the included cases who underwent operative intervention, between 01/01/2010 and 31/12/2019, are shown in Table 1. Co-morbidities (Table 1) were common and the majority of cases were undertaken for ‘acute dissection’ (55%).

Figure 1.

AVA Data extraction for vascular surgical intervention for TBAD. TBAD; type b aortic dissection. AVA: Australasian vascular audit.

Table 1.

Baseline characteristics of patients who underwent operative intervention for type b aortic dissection (TBAD) divided by method of surgical repair.

Characteristics	Total	TEVAR	OAR	p-value
n (%)	567	546 (96.3)	21 (3.7)
Age in years (median (range))	65 (10–94)	66 (10–94)	57 (28–84)	0.024*
Male	401 (70.7)	387 (70.9)	14 (66.7)	0.677
Hypertension	502 (88.5)	485 (88.8)	17 (81.0)	0.266
Ischaemic heart disease	153 (27.0)	149 (27.3)	4 (19.0)	0.404
Chronic kidney disease	45 (8.0)	45 (8.2)	0 (0)	0.160
Diabetes	42 (7.4)	42 (7.7)	0 (0)	0.187
Active smoker	86 (16.5)	83 (15.2)	3 (14.3)	0.822
Dissection classification
Acute dissection	312 (55.0)	310 (56.8)	2 (9.5)	<0.001*
Chronic dissection	128 (22.6)	127 (23.3)	1 (4.8)	—
Unclassified	127 (22.4)	109 (20.0)	18 (85.7)	—
Operative classification
Emergency	220 (38.8)	216 (39.6)	4 (19.0)	0.031*
Semi-urgent	168 (29.6)	163 (29.9)	5 (23.8)	—
Elective	179 (31.6)	167 (30.6)	12 (57.1)	—

Continuous data are presented as means ± standard deviations (SD), inter-quartile range (IQR). Categorical data are given as the counts (percentage). TEVAR; Thoracic endovascular aortic repair, OAR; Open aortic repair. * = p < 0.05.

The majority of patients were male (70.7%), those treated via TEVAR were notably older than those who underwent OAR (TEVAR: 66 (10–94) vs OAR: 57 (28–84) years, p = 0.024), and those who underwent TEVAR were more likely to be treated for ‘acute’ dissection in an ‘emergency’ setting.

Mortality (AVA data)

The overall in-hospital mortality following surgical intervention for TBAD was 5.3%. Of the study cohort, 12.3% were octogenarians with an overall mortality rate of 7.1%. There was a statistically significant survival benefit for TEVAR in comparison to OAR (4.8% vs 19.0%, p = 0.021). Gender was not associated with any differences in mortality across all procedures. The mortality breakdown by age, gender, dissection classification and operative urgency is shown in Table 2. Logistic regression highlighted a significant association between acute dissection as well as OAR with in-hospital mortality (Table 3).

Table 2.

In-hospital mortality following surgical intervention for TBAD.

Subgroups	Total n = 567	TEVAR n = 546	OAR n = 21
Total	30 (5.3)	26 (4.8)	4 (19.0)
Male	21 (5.2)	17 (4.4)	4 (28.6)
Female	9 (5.4)	9 (5.7)	0 (0)
By age group
<65 years	13 (4.7)	10 (3.8)	3 (20.0)
65–69 years	6 (6.4)	5 (5.5)	1 (33.3)
70–74 years	3 (4.8)	3 (4.9)	0 (0)
75–79 years	3 (4.9)	3 (4.9)	—
$\geq$ 80 years	5 (6.8)	5 (6.8)	0 (0)
By dissection classification
Acute dissection	20 (6.4)	20 (6.5)	0 (0)
Chronic dissection	2 (1.6)	2 (1.6)	0 (0)
Unclassified	8 (6.3)	4 (3.7)	4 (22.2)
By operative classification
Emergency	8 (3.6)	7 (3.2)	1 (25.0)
Semi-urgent	13 (7.7)	12 (7.4)	1 (20.0)
Elective	9 (5.0)	7 (4.2)	2 (16.7)

Table 3.

Logistic regression analysis of risk factors associated with in-hospital mortality.

	In-hospital mortality median (%/IQR)	Odds ratio	95% CI	p Value
Age >79 years	5 (6.8)	1.5	0.49–4.34	0.494
Female	9 (5.4)	1.1	0.46–2.54	0.865
Operative before 2015	13 (6.2)	1.1	0.53–2.49	0.733
Acute dissection	20 (6.4)	2.5	1.03–6.08	0.042*
Emergency operation	8 (3.6)	0.5	0.20–1.11	0.084
Open repair	4 (19.0)	6.1	1.60–23.56	0.008*
Unplanned return to theatre	3 (17.6)	4.0	0.93–17.55	0.063

Continuous data are presented as means ± standard deviations (SD), inter-quartile range (IQR). Categorical data are given as the counts (percentage). * = p < 0.05.

Morbidity (AVA data)

Several complications were more common following OAR as compared to TEVAR (Table 4): paraplegia (4.8% vs. 2.6%), stroke (4.8% vs. 2.2%) and post-operative haemorrhage (4.8% vs. 1.6%), although these were not statistically significant. Additionally, acute dissection was identified as resulting in a greater likelihood of gastrointestinal complication (p = 0.025), although this was not replicated in the cardiovascular, respiratory or neurological systems. Unplanned return to theatre following OAR was associated with a 50% mortality rate as compared to 13.3% for unplanned return following TEVAR. Median length of stay was significantly shorter in those undergoing TEVAR compared to OAR (11 vs 16 days, p < 0.01). The median LOS for both of these groups increased over time (TEVAR; 8 (2010) vs 10 days (2019), OAR; 13 (2010) vs 17 days (2019)). Additionally, acute dissection was shown to result in a prolonged admission compared to non-acute (median 14 vs 8 days, p < 0.01). Information as regards to ICU LOS as well as discharge destination (home vs. rehabilitation vs. residential care) was not available.

Table 4.

Complications following surgical intervention for TBAD.

Complications	Total n = 567	TEVAR n = 546	OAR n = 21
Acute myocardial infarction	5 (0.9)	5 (0.9)	0 (0)
Arrhythmia	3 (0.5)	3 (0.5)	0 (0)
Respiratory failure	7 (1.2)	7 (1.3)	0 (0)
Pneumonia	12 (2.1)	12 (2.2)	0 (0)
Renal impairment	3 (0.5)	3 (0.5)	0 (0)
Failure	10 (1.8)	10 (1.8)	0 (0)
Visceral ischaemia	6 (1.1)	6 (1.1)	0 (0)
Stroke	13 (2.3)	12 (2.2)	1 (4.8)
Paraplegia	15 (2.6)	14 (2.6)	1 (4.8)
Postoperative haemorrhage	10 (1.8)	9 (1.6)	1 (4.8)
Unplanned return to theatre	17 (3.0)	15 (2.7)	2 (9.5)

Trends in surgical management and outcomes of TBAD in Australia (AVA data)

The number of cases of TBAD undergoing intervention increased from 45 in 2010 to 88 in 2019 (Figure 2). Of the 567 procedures, 96.3% (n = 546) utilised TEVAR while 3.7% (n = 21) were OARs. The proportion of TEVARs was fairly stable over the period examined. However, the incidence of surgical intervention for ‘chronic dissection’ increased from 13.3% (6 cases) in 2010 to 27.3% (24 cases) in 2019. Overall, post-intervention mortality slightly improved between 2010 and 2019 (Figure 3). Mortality rates after intervention for ‘acute dissection’ were 8.7% in 2010, falling to 5.9% by 2019. Following ‘emergency’ repair, the mortality rate was relatively stable at 5.3% in 2010 compared to 5.9% in 2019.

Figure 2.

Number of cases of surgical intervention for TBAD in Australia (AVA data; 2010–2019). TBAD; type b aortic dissection, TEVAR; thoracic endovascular aortic repair, OAR; open aortic repair. AVA: Australasian vascular audit.

Figure 3.

Mortality rate following surgical intervention for TBAD in Australia (AVA data; 2010–2019). TBAD; type b aortic dissection, TEVAR; thoracic endovascular aortic repair, OAR; open aortic repair. AVA: Australasian vascular audit.

Trends in the age-standardized rates of TBAD in Australia (AIHW data)

According to AIHW data, between 2000-1 and 2018-9 the age-standardized rate of hospitalizations rose from 1.8 to 2.3/100 000 persons, procedure rates doubled from 0.5 to 1.0/100 000, and in-hospital deaths fell by 25% from 0.4 to 0.3/100 000 (Figure 4). Total deaths from TBAD (i.e. including non-hospital deaths) were not available as AIHW only records total deaths to four International Classification of Diseases characters (i.e. I71.0 [all aortic dissections] but not I71.01 [TBAD]). The age-standardized mortality for all dissections fell by 21% between 2000-1 and 2018-9. The proportion of admitted patients undergoing a procedure for TBAD rose from 28% in 2000-1 to 43% in 2018-9.

Figure 4.

Temporal trends in the age-standardised rates of TBAD in Australia from 2000–2001 to 2018–2019. TBAD; type b aortic dissection.

Discussion

The management of TBAD is currently one of the most debated topics in Vascular Surgery with ongoing uncertainty in regards to ideal management despite international guidelines.¹⁵ Munshi et al. recently conducted a survey of Australian and New Zealand (ANZ), and European vascular surgeons, which demonstrated significant heterogeneity in management strategies both nationally and internationally.¹⁶ Some of this uncertainty reflects the challenge of undertaking clinical trials on the management of TBAD.^8-10 This is further affected by the majority of observational cohort studies originating from high volume, specialized centres with results that may not always be generalizable.^13,17 The present analyses of a comprehensive national dataset, as well as population-based data, reflects comprehensive and generalizable outcomes. The authors have identified relatively low operative mortality following intervention for TBAD in the setting of increasing admissions and procedure rates. In the absence of new clinical trials on the management of TBAD, it is important to monitor these outcomes at either a national or regional level.

The overall in-hospital mortality rate of 5.3% (4.8% for TEVAR), seen in this Australian based cohort, is comparable to results in the recent literature with in-hospital mortality for TEVAR at between 2.6% and 9.8%.^18–21 It is also consistent with the 30-day mortality of 7.3% seen in recent American data from the Vascular Quality Initiative report.²² A somewhat older IRAD analysis estimated an overall in-hospital mortality rate of 13%, based on data obtained from 21 multi-national surgical centres.¹⁸ For open repair, the current study found the in-hospital mortality to be slightly higher than its international comparators. Whilst it was 19% for this Australian cohort, single-centres in the USA have been achieving 30-day mortality rates as low as 8.6%.^23,24 This discrepancy may be explained by a larger case volume spread across only a few dedicated centres in the United States.

The post-intervention mortality rate in both acute dissection and chronic dissection appears to have fallen in this cohort (2010–2019). This trend appears to be consistent with other studies.¹⁷ The reasons for the observed advances are unclear, but may include better and prompter medical management, enhanced surgical case selection and timing of intervention, as well as improving stent technology and increasing technical expertise. Not surprisingly, several post-intervention complications were more common following OAR compared to TEVAR. This is presumably because the most complex cases were not suitable for TEVAR and, as such, detailed comparison is not meaningful. The rate of key post-TEVAR complications such as renal impairment/failure, stroke and paraplegia were consistent with rates reported from comparable multi-centre studies.²²

The analysis of co-morbidities as risk factors for post-intervention mortality was limited by the available dataset. Of the co-morbidities recorded, none of them were independently associated with a statistically significant impact on in-hospital mortality. Interestingly, the in-hospital mortality for octogenarians was not grossly dissimilar to those aged 70–79 years. The rather limited impact of increasing age within our analysis is likely due to case selection which is exemplified by only one octogenarian undergoing OAR. Female gender has previously been shown to be associated with poorer outcomes following operative intervention for acute aortic dissection,^25,26 but this was not replicated within our analysis.

Surprisingly, the length of stay increased over time. Unfortunately, the AVA dataset does not yield any information on ICU LOS which does limit the interpretation of this finding. The finding that acute dissection had a longer admission period, when compared to non-acute, may be owed to in-patient monitoring of disease progression.

In Australia, there was a 28% increase in hospitalizations due to TBAD between the years 2000–2001 and 2018–2009. This increase confirms previously identified trends in both Sweden (1987–2002) and the USA (2000 and 2012).^27,28 The cause of the increase is still unclear. The trend is not due to an ageing population as it is still seen after adjusting for age. It probably relates to increasing diagnostic rates due to greater awareness and greater availability of CT scanning, particularly in emergency departments. In conjunction with the rise in hospitalizations, there has been an increase in the number of patients receiving operative management. In our cohort, this doubled across the investigated timeframe while the percentage of patients undergoing intervention for ‘chronic dissection’ rose from 13.3% to 27.3%. A similar trend was seen in the AIHW data with procedure rates doubling over nearly two decades. Reassuringly, despite the increase in both hospital admissions and the proportion of patients receiving operative intervention for TBAD, there has been a decline in the mortality rate across the time period examined. However, this was not found to be statistically significant when utilizing a logistic regression analysis to compare those who received operative intervention before 2015 and after. Given the current lack of conclusive clinical trial data, the monitoring of cohort and population-level outcomes contributes to the evidence base for the ongoing management of TBAD.

The strengths of the two sources of data used in this study are that they are large in size and representative of a ‘whole of service’ outcome. There are, however, several limitations to the AVA data. Firstly, it depends on the quality and detail of audit data (whilst the quality of the entries is audited, the mandatory entry is not). The data may be exposed to both information and selection bias secondary to incomplete, faulty or missed data. Furthermore, only five baseline risk factors were recorded and these were not strictly defined (potentially leading to an incomplete dataset). Complications such as ‘acute myocardial infarction’ also lacked a formal definition. Lastly, some dissection specific data is not routinely collected within the AVA dataset including: whether the dissections were complicated or uncomplicated; anatomical and clinical features; technical success; long term outcomes, complications and deaths after discharge.

The authors have sought to verify this utilizing other data sources. The AIHW data are population based and age-standardized, includes non-operative admissions, and is unlikely to be subject to any bias. Deaths from TBAD occurring outside hospital could not be identified as they are coded with all aortic dissection deaths – this should, however, not have influenced the pattern of the temporal trends.

Conclusion

This analysis of Australian data, from a large surgical audit database and from national morbidity and mortality records, demonstrates increasing rates of hospitalization and intervention for TBAD, with evidence of falling mortality rates. Ongoing monitoring of these trends and outcomes remains important in the absence of further clinical trial data concerning the management of TBAD.

Supplemental Material

Supplemental Material - Trends in the incidence, surgical mManagement, and oOutcomes of tType B aAortic dDissections in Australia over the lLast dDecade

Supplemental Material for Trends in the incidence, surgical Management, and Outcomes of Type B Aortic Dissections in Australia over the Last Decade by Ian Patrick Barry, Khay Seto, Paul E Norman, Jens C Ritter in Vascular

Footnotes

Acknowledgements

The authors are grateful for the data supplied by the Australian and New Zealand Society for Vascular Surgery Vascular Audit and the Cardiovascular, Diabetes and Kidney Unit of the Australian Institute of Health and Welfare.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Data availability statement

The data that support the findings of this study may be made available on request from the corresponding author.

Ethical approval

Approval for this study was granted by the institutional ethics committee. The committee determined that individual patient consent was not required, as there was no personally identifiable material within either dataset.

ORCID iD

Ian P Barry

Supplemental material

Supplemental material for this article is available online.

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Supplementary Material

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