Age-related difference in acute type B aortic dissection

Abstract

Objective

The objective is to compare the characteristics of clinical data, imaging data, and treatment methods of young and old patients with acute type B aortic dissection (ABAD).

Methods

ABAD patients admitted to the Department of Vascular Surgery of the First Affiliated Hospital of Anhui Medical University from January 2012 to December 2018 were retrospectively reviewed. Patient demographics, such as gender, age, diabetes, hypertension, presenting symptoms, imaging characteristics, laboratory data on admission, hemodynamics on admission and in-hospital management, and mortality of different age groups were compared and analyzed. Categorical variables were compared using χ² tests or Fisher’s exact test. Continuous variables were compared using Student’s t-test or Mann–Whitney U-test.

Results

A total of 141 ABAD patients were included in this study. Old ABAD patients were more likely to have a prior history of hypertension (88.6% vs 70.4%, p = 0.037) and atherosclerosis (29.8% vs 7.4%, p = 0.016). In the young group, Marfan syndrome was significantly higher (14.8% vs 0.9%; p = 0.005). Compared with the old group, the number of distal tears in the young group was significantly higher (62.3% vs 39.5%, p = 0.027). The proportion of patients with malperfusion of lower limbs in the young group was significantly higher than that in the old group (22.2% vs 6.1%, p = 0.026). There was no significant difference in the treatment methods and in-hospital mortality between the two groups.

Conclusion

Compared with old ABAD patients, young ABAD patients had more distal tears and a higher proportion of lower limbs malperfusion.

Keywords

Acute type B aortic dissection age treatment Marfan syndrome

Introduction

Aortic dissection (AD) is a cardiovascular emergency with high rate of morbidity and mortality and mortality.¹ The initial Debakey classification was proposed in 1965 to define the AD according to the anatomical characteristics. The more widely used Stanford classification is more simplified than the early Debakey classification and is based on whether the ascending aorta is affected.² European Society of Cardiology (ESC) guidelines divided the time course of AD into acute (<14 days), subacute (15–90 days), and chronic (>90 days) phases.³

Population-based studies suggested that the incidence of acute aortic dissection (AAD) may be between 2.6 and 3.5 cases per 100,000 person-years, and the incidence reported in autopsy series was between 0.2% and 0.8%.⁴ In 2004, the International Registry of Acute Aortic Dissection (IRAD) conducted a study of 951 cases of AAD in 18 centers and found that AAD patients under the age of 40 accounted for about 7% of the total AD patients.⁵ In general, the incidence of AAD in young people was low, and the current literature reports mainly focused on patients with acute type A aortic dissection (AAAD), and there were few reports on patients with acute type B aortic dissection (ABAD).^6–8 The objective of the current study was to compare the characteristics of clinical data, imaging data, and treatment methods of young and old patients with ABAD.

Materials and methods

Patient selection

A total of 141 ABAD patients admitted to the Department of Vascular Surgery of the First Affiliated Hospital of Anhui Medical University from January 2012 to December 2018 were retrospectively reviewed. This study was approved by the ethics committee of our hospital, and all patients gave informed consent. According to the World Health Organization (WHO) regulations on the division of human age groups in 2000, patients ≤45 years old were classified as the young group, and patients >45 years old were classified as the middle-aged and elderly group.⁹ In this study, patients over 45 years old were divided into the old group. All patients were diagnosed with ABAD by computed tomography angiography (CTA). The exclusion criteria for this study included: 1) Incomplete clinical data that cannot be evaluated; 2) penetrating atherosclerotic ulcer (PAU) and intramural hematoma (IMH); and 3) patients with chronic or subacute aortic dissection. Surgical or TEVAR treatment was performed during the initial hospitalization. The indications for surgical or TEVAR treatment include complex ABAD patients and high-risk ABAD patients. High-risk type B AD refers to the presence of any of the following risk factors: refractory pain, refractory hypertension, bloody pleural effusion, aortic diameter >40 mm, false lumen diameter >22 mm, radiographic only malperfusion, entry tear, lesser curve location, and readmission. This study complied with medical ethics standards and was approved by the Medical Ethics Committee of our hospital.

Data collection and definitions

Data collection included patient demographics, patient history, presenting symptoms, imaging characteristics, laboratory data on admission, hemodynamics on admission, in-hospital management, and in-hospital mortality. Imaging data were collected from the patient’s CTA on admission. In-hospital mortality was defined as any death that occurred during the initial hospitalization or within 30 days of discharge.

Statistical analysis

Statistical analysis was performed with SPSS, release 19.0 for Windows. Categorical variables were compared using χ² tests or Fisher’s exact test. Continuous variables were compared using Student’s t-test or Mann–Whitney U-test. All reported p values were two-sided, and p values < 0.05 were considered to be statistically significant.

Results

The baseline data of young and old patients with ABAD were shown in Table 1. Twenty-seven patients were included in the young group and 114 patients were included in the old group. Comparing the two groups, the average age of the patients in our study was 38.63 ± 4.99 vs 61.95 ± 8.52 years (p < 0.001). The male gender represents 77.8% of young patients vs 57.0% in old patients (p = 0.047). Presenting symptoms of ABAD were similar in both groups, the most common was chest pain (81.4% vs 77.2%, p = 0.629). Old ABAD patients were more likely to have a prior history of hypertension (88.6% vs 70.4%, p = 0.037) and atherosclerosis (29.8% vs 7.4%, p = 0.016). In the young group, Marfan syndrome was significantly higher (14.8% vs 0.9%; p = 0.005). There was no significant difference in other patient history between the two groups.

Table 1.

Baseline data of different age groups.

	Young group (age ≤ 45 years, n = 27)	Old group (age > 45 years, n = 114)	p value
Demographics
Male	24 (88.9)	90 (78.9)	0.238
Age	38.63 ± 4.99	61.95 ± 8.52	<0.001
Presenting symptoms
Chest pain	22 (81.4)	88 (77.2)	0.629
Back pain	10 (37.0)	38 (33.3)	0.715
Abdominal pain	4 (14.8)	27 (23.7)	0.317
Syncope	2 (7.4)	6 (5.3)	1.000
Patient history
Hypertension	19 (70.4)	101 (88.6)	0.037
DM	2 (7.4)	11 (9.6)	1.000
Marfan syndrome	4 (14.8)	1 (0.9)	0.005
Atherosclerosis	2 (7.4)	34 (29.8)	0.016
Previous cardiac surgery	2 (7.4)	10 (8.8)	1.000
Previous aortic dissection	1 (3.7)	3 (2.6)	0.577
Previous aortic aneurysm	0 (0)	4 (3.5)	1.000
Smoking	13 (48.1)	60 (52.6)	0.675
CKD	4 (14.8)	13 (11.4)	0.872

DM, diabetes mellitus; CKD, chronic kidney disease.

Laboratory data and hemodynamics on admission were shown in Table 2. The white blood cells in the young group were significantly higher than those in the old group (12.89 ± 3.11 vs 10.65 ± 2.82, p < 0.001). Triglycerides were also significantly higher in the young group than in the old group (1.63 ± 0.46 vs 1.42 ± 0.44, p = 0.034). Other laboratory data showed no significant difference between the two groups. Both systolic blood pressure (SBP) and diastolic blood pressure (DBP) on admission were higher in the older group than in the younger group, but the results were not significantly different (143 [127.00–160.00] vs 138.00 [126.00–146.00], p = 0.085; 88.00 [75.00–100.00] vs 84.00 [78.00–92.00], p = 0.256). The heart rate of the young group was higher than that of the old group, and there was no significant difference (86.00 [71.00–99.00] vs 82.00 [67.00–94.25], p = 0.307).

Table 2.

Laboratory data and hemodynamics on admission of different age groups.

	Young group (age ≤45 years, n = 27)	Old group (age > 45 years, n = 114)	p value
Laboratory data on admission
WBC (x 10⁹/L)	12.89 ± 3.11	10.65 ± 2.82	<0.001
PLT (x 10⁹/L)	202.48 ± 58.70	188.52 ± 42.22	0.252
CRP (mg/L)	31.04 ± 12.06	33.53 ± 13.09	0.369
D-dimer (ug/L)	2.20 [0.90–5.10]	2.45 [1.88–5.40]	0.135
TC (umol/L)	3.91 ± 0.63	4.12 ± 0.61	0.136
TG (mmol/L)	1.63 ± 0.46	1.42 ± 0.44	0.034
Cr (umol/L)	94.75 ± 35.26	98.24 ± 24.58	0.629
Hemodynamics on admission
SBP (mmHg)	138.00 [126.00–146.00]	143 [127.00–160.00]	0.085
DBP (mmHg)	84.00 [78.00–92.00]	88.00 [75.00–100.00]	0.256
HR (bpm)	86.00 [71.00–99.00]	82.00 [67.00–94.25]	0.307

WBC, white blood cell; PLT, platelet; CRP, C-reactive protein; TC, total cholesterol; TG, triacylglycerol; Cr, creatinine; SBP, systolic blood pressure; DBP, diastolic blood pressure; HR, heart rate.

Imaging characteristics were shown in Table 3. In the young group, most of the proximal tears location were distributed in the greater curvature, which was similar to the distribution of the old group (66.7% vs 77.2%, p = 0.654). The length of the proximal tears were 13.2 ± 4.0 mm in the young group and 11.6 ± 7.4 mm in the old group, with no significant difference between the two groups (p = 0.379). Compared with the old group, the number of distal tears in the young group was significantly higher (62.3% vs 39.5%, p = 0.027). The proportion of distal extension of the dissections under the diaphragm (IIIb) in the young group was higher than that in the old group, but there was no significant difference between the two groups (74.1% vs 60.5%, p = 0.190). There was no significant difference in the incidence of malperfusion between the two groups, but the proportion of patients with malperfusion of lower limbs in the young group was significantly higher than that in the old group (22.2% vs 6.1%, p = 0.026). The ratio of partial thrombosis of false lumen and pleural effusion was similar between the young group and the old group.

Table 3.

Imaging characteristics of different age groups.

Variable	Young group (age ≤45 years, n = 27)	Old group (age > 45 years, n = 114)	p value
Location of proximal tear
Smaller curvature	6 (22.2)	27 (23.7)	0.872
Greater curvature	18 (66.7)	81 (77.2)	0.654
Far from the descending part of the aortic arch	3 (11.1)	6 (5.3)	0.497
Length of proximal tear (mm)	13.2 ± 4.0	11.6 ± 7.4	0.379
Distal tear	17 (62.3)	45 (39.5)	0.027
Extent of aortic dissection
Involvement of thoracic aorta	3 (11.1)	47 (41.2)	0.003
Abdominal aorta	6 (22.2)	32 (28.1)	0.538
Iliac arteries	18 (66.7)	35 (30.7)	0.001
Malperfusion
Celiac axis	1 (3.7)	2 (1.8)	0.474
SMA	2 (7.4)	4 (3.5)	0.710
Renal artery	5 (18.5)	12 (10.5)	0.413
Lower limb artery	6 (22.2)	7 (6.1)	0.026
Partial thrombosis of false lumen	10 (37.0)	40 (35.1)	0.849
Pleural effusion	5 (18.5)	17 (14.9)	0.865

SMA, superior mesenteric artery.

In-hospital management and mortality were shown in Table 4. In the young group, endovascular therapy was performed in 15 patients (55.5%), seven patients (25.9%) were treated with medical therapy, and surgical intervention was performed in five patients (18.1%). In the old group, endovascular therapy was performed in 68 patients (59.6%), 39 patients (34.2%) were treated with medical therapy, and surgical intervention was performed in seven patients (6.1%). There was no significant difference in the treatment methods between the two groups. One young ABAD patient died in hospital and four old ABAD patients died in hospital (3.7% vs 3.5%, p = 1.000).

Table 4.

In-hospital management and mortality of different age groups.

Treatment	Young group (age ≤45 years, n = 27)	Old group (age > 45 years, n = 114)	p value
Endovascular management	15 (55.5)	68 (59.6)	0.698
Medical management	7 (25.9)	39 (34.2)	0.409
Surgical management	5 (18.5)	7 (6.1)	0.091
In-hospital mortality	1 (3.7)	4 (3.5)	1.000

Discussion

The incidence of AAD in young population is low, but there is an increasing trend. Compared with western countries, the incidence of AAD in young Chinese people is higher.¹⁰ There were 27 young patients in this study, accounting for 19.1% of the total ABAD patients. The proportion of male patients in the young group was significantly higher than that in the old group. However, few studies have investigated the impact of gender on patients with ABAD. Takahashi et al. identified 2372 patients with ABAD in the Tokyo Acute Aortic Super-Network Registry found that female patients with ABAD were fewer and older than male patients. In addition, female patients had more intramural hematoma (63.7% vs 53.7%, p < 0.001) and were more medically treated (90.9% vs 86.3%, p = 0.002).¹¹ Liang et al. analyzed data about 9855 ABAD patients from the National Inpatient Sample datasets. It was found that there were fewer females patients (43.6%, n = 4293) and they experienced ABAD at a later age (69.8 ± 15.5 vs 62.8 ± 15.6, p < 0.001). Female patients had more comorbidities (heart failure, COPD, diabetes, and rheumatic diseases) and were medically managed more frequently (87.4% vs 81.8%; p < 0.001).¹²

The prevalence of hypertension among Chinese adults increased from 11.3% in 1991 to 18.0% in 2002 and 26.6% in 2013.^13–15 A study on 898,929 people in 2019 showed that the prevalence of hypertension among young Chinese (aged 35 to 49 years) was 26.2%. In the subgroup analysis of isolated systolic hypertension patients, 86.7% of the patients did not receive treatment, and less than 7% of the patients knew that they had hypertension.¹⁶ The alarming trend of rising hypertension and lack of awareness may contribute to the growth of ABAD in young people. In this study, the incidence of hypertension in the young group was lower than that in the old group (70.4% vs 88.6%, p = 0.037), but the incidence of both groups was much higher than that of the general population. Marfan syndrome is inherited in an autosomal dominant connective tissue disorder, with 1 in 3–5000 people affected, regardless of race or geographical location.¹⁷ An IRAD study included 6424 AAD patients, 258 of whom (4%) were diagnosed with Marfan syndrome. The age of Marfan syndrome patients was significantly lower than that of patients without Marfan syndrome (38.2 ± 13.2 years vs 63.0 ± 14.0 years; p < 0.001). The combined follow-up data of type A and type B AAD showed that the 5-year survival rate of Marfan syndrome patients was estimated to be 80.1%, and the reintervention rate was estimated to be 55.3%. This high reintervention rate highlights the need for careful monitoring and treatment of AAD patients with Marfan syndrome.¹⁸ In this study, the incidence of Marfan syndrome in young and middle-aged ABAD patients was significantly higher than that in the elderly group, and it is necessary to diagnose Marfan syndrome in young ABAD patients as early as possible. The diagnostic criteria for Marfan syndrome were recently revised in 2010 and are known as Ghent II nosology.¹⁹

Most of the proximal tears in both groups were located on the greater curvature. However, the proportion of distal tears in the young group was significantly higher than that in the old group. There is increasing evidence that distal tears may increase the risk of late aortic events and hinder aortic remodeling.^20–22 Chenmou et al. retrospectively analyzed the clinical results of 130 ABAD patients who received thoracic endovascular aortic repair (TEVAR). Patients were divided into group A (without distal tears) and group B (with distal tears) according to whether there were distal tears after TEVAR. The results showed that the incidence of late aortic events in group A was significantly lower than that in group B (p = 0.028). The aortic remodeling in group A was superior to group B in complete thrombosis of the thoracic aortic false lumen at 12 months postoperatively (100% vs 83.5%; p = 0.029).²⁰ Mikolaj et al. demonstrated that selective exclusion of distal tears after TEVAR at the abdominal aorta level appears to be a viable way to promote false lumen thrombosis. It effectively stabilizes thoracoabdominal aortic dilatation in most patients with type B AD and may reduce mortality.²³

There were not many studies comparing the distal extension of ABAD between young and old patients. Studies from Germany and the United Kingdom had shown that dissection was more extensive in young patients with AAAD.^7,24 This study suggested that dissection is also more extensive in young patients with ABAD. Malperfusion may involve renal arteries, celiac axis, SMA, and lower limb artery. The proportion of young group with lower limb malperfusion (LLM) was 22.2%, which was significantly higher than that of the old group (6.1%). Kimura et al.'s study included 30 young AAAD patients and 325 old AAAD patients, but there was no significant difference in the incidence of LLM (16.7% vs 11.2%, p > 0.05).⁸ The incidence of LLM was 5%–12% in TBAD and 40% in complicated TBAD. A systematic review by Gargiulo et al. included 29 papers and reported 138 patients with LLM secondary to TBAD. There were 134 patients (97%) of acute and four patients (3%) of chronic TBAD, respectively. A total of 120 (87%) LLM patients had acute limb ischemia. The 30-day mortality after surgery and endovascular treatment was 14% (5/36) and 8% (2/26), respectively.²⁵ For AAAD patients with symptoms of LLM, timely intervention and appropriate treatment should be conducted to avoid the occurrence of death events.

Joker et al.’s paper reported the prognosis of 583 complicated ABAD patients in IRAD from 1996 to 2012. The study found that the use of surgical and endovascular treatment decreased gradually with patient age, while the rate of medical management increased significantly with age (p < 0.001). A total of 37% of patients under 70 years of age received endovascular therapy compared to 24% of patients 70 years of age or older (p < 0.001).²⁶ In our study, the proportion of endovascular management was significantly higher than that of medical therapy and surgical intervention in both groups, which benefited from the maturity of endovascular technology and the progress of instruments in recent years. According to the 2022 ACC/AHA guidelines, in patients with complicated ABAD, endovascular treatment is more effective than surgical and medical therapy. In patients with uncomplicated ABAD, medical therapy as the initial management strategy is recommended. However, in patients with uncomplicated ABAD who have high-risk anatomic features, endovascular management may be considered.²⁷ For uncomplicated ABAD, the 5-year follow-up results of INSTEAD study showed that endovascular treatment had better aortic remodeling than simple medical management, and had the potential to reduce the risk of long-term aorta-related adverse events. In addition, the 11-year follow-up results of a study from China confirmed that the risk of aorta-related adverse events and mortality of patients treated with TEVAR were lower than those treated with medical management alone.^28,29

This study had several limitations. First, this study was a single-center study and lacked a large sample, which failed to provide high-quality evidence. Second, the study failed to provide long-term follow-up to obtain more valuable data. Finally, we did not conduct a detailed analysis and discussion of the treatment methods of the two groups of patients.

Conclusion

Compared with old ABAD patients, young ABAD patients had more distal tears and a higher proportion of lower limb malperfusion.

Footnotes

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) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by a grant from the National Natural Science Foundation of China (No. 81100251).

ORCID iDs

Zhigong Zhang

Feng Lin

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