and Outcomes in Patients With Uncomplicated Type B Aortic Dissection - PowerPoint PPT Presentation

Racial Differences In Patterns of Presentation and Outcomes in Patients With Uncomplicated Type B Aortic Dissection Matthew Aizpuru BA 1 , Xiaoying Lou MD 2 , Jaime Benarroch-Gampel MD 1 , William D Jordan Jr. MD 1 , Bradley G Leshnower MD 2 , & Robert S Crawford MD 1 Emory University School of Medicine Department of Surgery Division of Vascular Surgery 1 and Division of Cardiothoracic Surgery 2 Atlanta, Georgia emoryhealthcare.org/vascular emoryhealthcare.org/vascular 1

DISCLOSURES • The speaker has no financial or other conflicts of interest to disclose. emoryhealthcare.org/vascular 2

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 outcomes remain poor overall. emoryhealthcare.org/vascular 3

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) emoryhealthcare.org/vascular 4

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. emoryhealthcare.org/vascular 5

INTRODUCTION • Administrative database of TAAD & TBAD • Non-White patients present younger & more female • No difference in comorbidities, access to care or mortality emoryhealthcare.org/vascular 6

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 emoryhealthcare.org/vascular 7

INTRODUCTION • Single institution • Complicated TBAD • AA present younger & with worse BP control • White patients have inferior survival at 5 years emoryhealthcare.org/vascular 8

OBJECTIVE • Describe racial differences in presentation and outcomes in patients with uncomplicated Type B Aortic Dissection (uTBAD). emoryhealthcare.org/vascular 9

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 emoryhealthcare.org/vascular 10

RESULTS 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 emoryhealthcare.org/vascular 11

RESULTS 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 emoryhealthcare.org/vascular 12

RESULTS: PRESENTATION Anatomical Factor AA White p 4.6 4.7 0.2 Diameter of Thoracic Aorta (cm) 3.7 3.6 0.9 Diameter of Abdominal Aorta (cm) 71% 72% 0.8 Thoracoabdominal Extension 53% 50% 0.8 Patent False Lumen emoryhealthcare.org/vascular 13

RESULTS: PRESENTATION Anatomical Factor AA White p 4.6 4.7 0.2 Diameter of Thoracic Aorta (cm) 3.7 3.6 0.9 Diameter of Abdominal Aorta (cm) 71% 72% 0.8 Thoracoabdominal Extension 53% 50% 0.8 Patent False Lumen Anatomically Similar on Presentation emoryhealthcare.org/vascular 14

RESULTS: FOLLOW UP Anatomical Factor AA White p 5.2 5.4 0.3 Diameter of Thoracic Aorta (cm) 0.06 0.02 0.1 Growth of Thoracic Aorta (cm/week) 3.7 3.6 0.6 Diameter of Abdominal Aorta (cm) Growth of Abdominal Aorta (cm/week) -0.01 0.01 0.4 42% 40% 0.8 Patent False Lumen emoryhealthcare.org/vascular 15

RESULTS: FOLLOW UP Anatomical Factor AA White p 5.2 5.4 0.3 Diameter of Thoracic Aorta (cm) 0.06 0.02 0.1 Growth of Thoracic Aorta (cm/week) 3.7 3.6 0.6 Diameter of Abdominal Aorta (cm) Growth of Abdominal Aorta (cm/week) -0.01 0.01 0.4 42% 40% 0.8 Patent False Lumen Anatomically Similar on Follow Up emoryhealthcare.org/vascular 16

RESULTS: MANAGEMENT Indication for Intervention AA White Growth/Size N=60(86%) N=46(84%) Pain or Malperfusion N=10(14%) N=9(16%) No Difference in Indication for Surgery (p=.7) emoryhealthcare.org/vascular 17

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%) 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%) More Interventions for White Pts (p=.004), Predominantly TEVAR/EVAR emoryhealthcare.org/vascular 19

RESULTS: MANAGEMENT Operative Treatment AA White Open Repair N=35(50%) N=18(33%) TEVAR/EVAR N=35(50%) N=37 (67%) 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%) More Open Surgery for AA (p=0.05) emoryhealthcare.org/vascular 21

RESULTS: SURGICAL Outcome AA (n=70) White (n=55) p N=8 (11%) N=3 (5%) 0.2 In-Hospital Mortality Major Complication or Death N=18 (26%) N=4 (7%) 0.01 (Sum)* Re-intervention N=14 (20%) N=10 (18%) 0.8 *Major complication defined as stroke, spinal cord ischemia or renal failure emoryhealthcare.org/vascular 22

RESULTS: SURGICAL Outcome AA (n=70) White (n=55) p N=8 (11%) N=3 (5%) 0.2 In-Hospital Mortality Major Complication or Death N=18 (26%) N=4 (7%) 0.01 (Sum)* Re-intervention N=14 (20%) N=10 (18%) 0.8 Increased Perioperative Morbidity/Mortality for AA *Major complication defined as stroke, spinal cord ischemia or renal failure emoryhealthcare.org/vascular 23

RESULTS: KAPLAN MEIER INTERVENTION FREE SURVIVAL AA 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% Wh Number at Risk 65 34 22 p=.05 Decreased IFS at 5 years for White Pts emoryhealthcare.org/vascular 24

RESULTS: KAPLAN MEIER ALL CAUSE SURVIVAL AA 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 Wh White All Cause Survival 89 % 78% 71% 45% p=.17 Number at Risk 79 63 46 16 No difference in survival up to 10 years emoryhealthcare.org/vascular 25

CONCLUSIONS • African Americans with uTBAD present younger, with more comorbidities. • African Americans have more open operations. • These increases in open surgery may be due to the younger age of African Americans. • AA have more perioperative morbidity & mortality. emoryhealthcare.org/vascular 26

CONCLUSIONS • 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 emoryhealthcare.org/vascular 27

Thank You emoryhealthcare.org/vascular 28

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% vs 81%, p=.13). emoryhealthcare.org/vascular 29