Aortic dissection: pleural rupture and dissection complications increased the risk of dying

Clinical bottom line (level 2b)

  1. A fifth of patients who had an aortic dissection were dead within 30 days.
  2. Patients were at increased risk of dying if they had
    • a pleural rupture
    • complications of dissection at presentation
    • increasing age
    • cardiac disease
  3. Medical therapy compared with surgical therapy was not clearly more likely to increase the risk of dying.
  4. Roughly 10% of patients required subsequent surgery in the next 7 years.
Glower et al: Circulation 1990; 82: 39-46
Expires October 2004

The study

Retrospective cohort study with objective outcomes, adjusted for confounding factors, not validated in an independent set of patients.

Setting: 2 university hospitals, USA

136 patients (aged mean 64, 69% male) with a descending aortic dissection (type B - 64% acute) (confirmed on angiography, CT, MRI, operation or autopsy)

Factors studied:
  • age, sex, dissection complications, cardiac disease, treating institution, prior operation, arch involvement, thoracoabdominal dissection, type of treatment (medical or surgery)


    • Patients either had surgery (an aortic graft) or were admitted to an intensive care unit for blood pressure control with beta-blockers and vasodilators. All patients were treated chronically with beta-blockers and additional antihypertensive agents as required.

    Multivariate Cox regression analysis performed on prognostic factors.

    96% followed for 30 days
    Outcomes studied:
  • death
  • subsequent surgical intervention

    • The evidence

    outcome time to outcome number of patients/total number %
    (95% CI)    		 NNF
    (95% CI)
    death 30 days 25/136 18%
    (12% to 25%)    		 5
    (4 to 8)
    subsequent surgical intervention 7 years 13/136 9.6%
    (4.6% to 15%)    		 10
    (7 to 22)

    • Independent predictors of mortality included
      • pleural rupture
      • dissection complications at presentation (pulse loss, renal or visceral ischaemia, myocardial infarction, stroke, renal failure or paralysis)
      • increasing age
      • cardiac disease
    • Type of therapy (medical or surgery) was not found to be significantly associated with survival even for patients with a chronic dissection.

    Comments

    1. 5 surgical patients required further surgery, and 8 medical patients required further surgery - this is not significantly different.
    2. Medical patients spent a mean of 8 days fewer in hospital (95% CI: 4 to 12).
    3. No odds ratios provided for prognostic factors.

    Citation

    1. Glower DD, Fann JI, Speier RH, et al: comparison of medical and surgical therapy for uncomplicated descending aortic dissection (supplement IV). Circulation 1990; 82: 39-46
    Search Terms: aortic near dissect* in PubMed Clinical queries (therapy sensitivity)
    Contributor: Chris Ball and Clare Wotton, October 1999
    Reviewer:

    Clinical Question.
    Patient aortic dissection
    Intervention or Exposure medical or surgical therapy, complications
    Outcome death