Impact of aortic dimensions and pulse pressure on late aneurysm formation in operated type A aortic dissection. A magnetic resonance imaging study

  • Ana G. Almeida
  • Ângelo L. Nobre
  • Ricardo A. Pereira
  • Altamiro Costa-Pereira
  • Clara Tavares
  • João Cravino
  • Mário G. Lopes
Original Paper

Abstract

Background Patients operated on for type A aortic dissection remain at risk of long-term aneurysm development, the main cause for late death. The aim of this study was to identify early predictors for aneurysm formation at three-years after surgery. Methods A study group of 70 consecutive patients (52 ± 10 years-old, 41 male), operated on for aortic dissection with replacement of the ascending segment, was evaluated prospectively for three-years. In order to detect aneurysm formation, the dimension of residual distal aortic segments was obtained soon after surgery and then annually for three years using cardiovascular magnetic resonance. Results During follow-up (38 ± 2.6 months), aneurysm was found in 25 patients (35%) involving residual segments. Larger initial dimension of segments, higher pulse pressure, lower distensibility of residual segments and the presence of a residual flap were univariately associated with aneurysm. Multivariate analysis identified the initial dimension (mm) of the descending thoracic aorta (OR 1.47, 95%CI: [1.19–1.82]) and pulse pressure (OR 1.43,95%CI: [1.10–1.86]) as independent variables for aneurysm formation. A risk score using pulse pressure and descending thoracic dimension was constructed. Patients with ≤24 points had no late aneurysm formation, while those with a score ≥45 yielded 100% of aneurysm frequency. Conclusions Type A aortic dissection treated by graft interposition is associated with a high risk of aneurysm formation. Early post-operative pulse pressure and the descending thoracic aortic dimension were independent variables and seem to be the main predictors for the outcome.

Keywords

Aortic dissection Cardiovascular Magnetic Resonance Cardiovascular surgery Prognosis 

Abbreviations

BSA

Body surface area

ICC

Interclass correlation coefficient

CMR

Cardiovascular magnetic resonance

OR

Odds ratio

ROC

Receiver operator characteristic

References

  1. 1.
    Lytle BW, Mahfood SS, Cosgrove DM, Loop FD (1990) Replacement of the ascending aorta: early and late results. J Thorac Cardiovasc Surg 99:651–658PubMedGoogle Scholar
  2. 2.
    Ehrlich MP, Ergin MA, McCullough JN et al (2000) Results of immediate surgical treatment of all acute type A dissections. Circulation 102(suppl III):III-248–III-252Google Scholar
  3. 3.
    Mehta RH, Suzuki T, Hagan PG et al (2002) Predicting death in patients with acute type A aortic dissection. Circulation 105:200–206CrossRefPubMedGoogle Scholar
  4. 4.
    Doroghazi RM, Slater EE, DeSanctis RW et al (1984) Long-term survival of patients with treated aortic dissection. J Am Coll Cardiol 3:1026–1034PubMedCrossRefGoogle Scholar
  5. 5.
    Kawahito K, Adachi H, Yamaguchi, Ino T (2001) Preoperative risk factors for hospital mortality in acute type A aortic dissection. Ann Thorac Surg 71:1239–1243CrossRefPubMedGoogle Scholar
  6. 6.
    Gott VL, Greene PS, Alejo DE et al (1999) Replacement of the aortic root in patients with Marfan´s syndrome. N Engl J Med 340:1307–1313CrossRefPubMedGoogle Scholar
  7. 7.
    Januzzi JL, Marayati F, Mehta RH et al (2004) Comparison of aortic dissection in patients with and without Marfan’s syndrome (results from the International registry of aortic dissection). Am J Cardiol 94:400–402CrossRefPubMedGoogle Scholar
  8. 8.
    Barron DJ, Livesey SA, Brown IW et al (1997) Twenty-years follow-up of acute type A dissection: the incidence and extent of distal aortic disease using magnetic resonance imaging. J Card Surg 12:147–159CrossRefPubMedGoogle Scholar
  9. 9.
    Bernard Y, Zimmermann H, Chocron S et al (2001) False lumen patency as a predictor of late outcome in aortic dissection. Am J Cardiol 87:1378–1382CrossRefPubMedGoogle Scholar
  10. 10.
    Yeh C, Chen M, Wu Y et al (2003) Risk factors for descending aortic aneurysm formation in medium-term follow-up of patients with type A aortic dissection. Chest 124:989–995CrossRefPubMedGoogle Scholar
  11. 11.
    Chiappini B, Schepens M, Tan E et al (2005) Early and late outcomes of acute type A aortic dissection: analysis of risk factors in 487 consecutive patients. Eur Heart J 26:180–188CrossRefPubMedGoogle Scholar
  12. 12.
    Halstead JC, Meier M, Etz C et al (2007) The fate of distal aorta after repair of acute type A aortic dissection. J Thorac Cardiovasc Surg 133:127–135CrossRefPubMedGoogle Scholar
  13. 13.
    Nienaber CA, von Kodolitsch Y, Nicolas V et al (1993) The diagnosis of thoracic aortic dissection by noninvasive imaging procedures. N Engl J Med 328:1–9CrossRefPubMedGoogle Scholar
  14. 14.
    Fattori R, Bacchi-Reggiani L, Bertaccini P et al (2000) Evolution of aortic dissection after surgical repair. Am J Cardiol 86: 868–872CrossRefPubMedGoogle Scholar
  15. 15.
    Davies RR, Goldstein LJ, Coady MA et al (2002) Yearly rupture or dissection rates for thoracic aortic aneurysms: simple prediction based on size. Ann Thorac Surg 73:17–27CrossRefPubMedGoogle Scholar
  16. 16.
    Elefteriades JA (2002) Natural history of thoracic aortic aneurysms: indications for surgery and surgical versus nonsurgical risks. Ann Thorac Surg 74:S1877–S1890CrossRefPubMedGoogle Scholar
  17. 17.
    Brewsrter DC, Cronenwett JL, Hailett JW Jr et al (2003) Guidelines for the treatment of abdominal aortic aneurysms. J Vasc Surg 37:1106–1117CrossRefGoogle Scholar
  18. 18.
    Bogren HG, Buonocore MH (1999) Complex flow patterns in the great vessels: a review. Int J Card Imaging 15:105–113CrossRefPubMedGoogle Scholar
  19. 19.
    Kato M, Bai H, Sato K et al (1995) Determining surgical indications for acute type B dissection based on enlargement of aortic diameter during chronic phase. Circulation 92:9(Suppl II) 107–112Google Scholar
  20. 20.
    Robicsek F, Thubrikar MJ (1994). Hemodynamic considerations regarding the mechanism and prevention of aortic dissection. Ann Thorac Surg 58:1247–1253PubMedCrossRefGoogle Scholar
  21. 21.
    Milewicz DM, Michael K, Fisher N et al (1996) Fibrillin-1 (FBN1) mutations in patients with thoracic aortic aneurysms. Circulation 94:2708–2711PubMedGoogle Scholar
  22. 22.
    Jeremy RW, Huang H, Hwa J, McCarron H et al (1994) Relation between age, arterial distensibility and aortic dilatation in the Marfan syndrome. Am J Cardiol 74:269–373CrossRefGoogle Scholar
  23. 23.
    Mohiaddin R, Firmin D, Longmore D (1993) Age-related changes of human aortic flow wave velocity measured non-invasively by magnetic resonance imaging. J Appl Physiol 74:492–497PubMedGoogle Scholar
  24. 24.
    Nollen GJ, Groenink M, Tijssen J et al (2004) Aortic stiffness and diameter predict progressive aortic dilatation in patients with Marfan syndrome. Eur Heart J 25:1146–1152CrossRefPubMedGoogle Scholar
  25. 25.
    Williams DM, Le Page MA, Lee DY (1997) The dissected aorta. Early anatomic changes in a in vitro model. Radiology 203:23–31PubMedGoogle Scholar
  26. 26.
    Hachiya J, Nitatori T, Yoshino A et al (1993) CT of calcified chronic aortic dissection simulating atherosclerotic aneurysm. J Comput Assist Tomogr 17:374–378CrossRefPubMedGoogle Scholar
  27. 27.
    Groenink M, Langerak SE, Vanbavel ED et al (1999) The influence of aging and aortic stiffness on permanent dilation and breaking stress of the thoracic descending aorta. Cardiovasc Res 43:471–480CrossRefPubMedGoogle Scholar
  28. 28.
    Groenink M, de Roos A, Mulder BJ et al (1998) Changes in aortic distensibility and pulse wave velocity assessed by magnetic resonance imaging following beta-blocker therapy in the Marfan syndrome. Am J Cardiol 82:203–208CrossRefPubMedGoogle Scholar
  29. 29.
    Jondeau G, Boutouyrie P, Lacolley P et al (1999) Central pulse pressure as a major determinant of ascending aorta dilatation in Marfan syndrome. Circulation 99:2677–2681PubMedGoogle Scholar
  30. 30.
    Shores J, Berger KR, Murphy EA, Pyeritz RE (1994) Progression of aortic dilatation and the benefit of long-term (beta)-adrenergic blockade in Marfan´s syndrome. N Engl J Med 330:1335–1341CrossRefPubMedGoogle Scholar
  31. 31.
    Domanski MJ, Mitchell GF, Norman JE et al (1999) Independent prognostic information provided by sphygmomanometrically determined pulse pressure and mean arterial pressure in patients with left ventricular dysfunction. J Am Coll Cardiol 33:951–958CrossRefPubMedGoogle Scholar
  32. 32.
    Erbel R, Oelert H, Meyer J et al (1993) Effect of medical and surgical treatment on aortic dissection evaluated by TEE. Circulation 87:1604–1615PubMedGoogle Scholar
  33. 33.
    Sabik JF, Lytle BW, Blackstone EH et al (2000) Long-term effectiveness of operations for ascending aortic dissections. J Thorac Cardiovasc Surg 119:942–962CrossRefGoogle Scholar
  34. 34.
    Myrmel T, Lai DTM, Miller DC (2004) Can the principles of evidence-based medicine be applied to the treatment of aortic dissections? Eur J Cardiothoracic Surg 25:236–242CrossRefGoogle Scholar
  35. 35.
    Stefanadis C, Stratos C, Boudoulas H et al (1990) Distensibility of the ascending aorta: comparison of invasive and non-invasive techniques in healthy men and in men with coronary artery disease. Eur Heart J 11:990–996PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media B.V. 2008

Authors and Affiliations

  • Ana G. Almeida
    • 1
  • Ângelo L. Nobre
    • 1
  • Ricardo A. Pereira
    • 1
  • Altamiro Costa-Pereira
    • 2
  • Clara Tavares
    • 2
  • João Cravino
    • 1
  • Mário G. Lopes
    • 1
  1. 1.Cardiology and Cardiothoracic Surgery Service, University Hospital Santa Maria, Faculty of MedicineLisbon UniversityLisbonPortugal
  2. 2.Department of Biostatistics and Medical Informatics, Faculty of MedicinePorto UniversityPortoPortugal

Personalised recommendations