Aortic Dissection in Elderly Patients
A previously healthy 84-year-old gentleman presented to the emergency room with undulating chest and back pain after he had recovered from a presyncope an hour ago; he reported a history of arterial hypertension and the use of beta-blocker and vasodilator medication, such as ramipril and oral nitrates, for some years. Until recently he was actively engaging in recreational exercise and moderate weight lifting. Upon admission, he was normotensive at 130/70 mm Hg with a pulse differential between both femoral arteries of 30 mm Hg. Once a normal (non-ischemic) 12-lead electrocardiogram (ECG) was recorded (with left axis deviation) he was subjected to contrast-enhanced computed tomography (CT) imaging, revealing type B aortic dissection (Figure 1, Panel A) with a narrow true lumen and compromised perfusion of the left common iliac artery, thus fulfilling criteria of distal dissection complicated by leg ischemia.1,2,3,4
Panel A demonstrates a three-dimensional (3-D) reconstruction of a computed tomography angiogram showing a classic type B aortic dissection in an 84-year-old male patient. The dissection originates at the level of the left subclavian artery and extends into the aortic bifurcation with morphologic signs of true lumen collapse in absence of major false lumen expansion.
Panel B reveals in similar orientation the previously, reconstructed aorta after placement of a proximal stent-graft and an overlapping distal bare-metal stent component; there is no branch obstruction of both the celiac trunk and the arteria mesenterica superior.
While the controversy over the most appropriate management of type B dissection remains unresolved, particularly in elderly patients without evidence of (contained) aortic rupture, this patient was considered at risk due to his lower extremity pulse differential regardless of his advanced age. Thus, based on the individual biological condition without major life-limiting comorbidities, the patient was offered undelayed endovascular stent graft repair in the attempt to both reconstruct the dissected aorta and alleviate peripheral ischemia. Under local anesthesia and with exposure of the right femoral artery, thoracic endovascular aneurysm repair (TEVAR) was successfully performed under ultrasound guidance,5 and flow was successfully redirected to the true lumen after sealing proximal thoracic entries by use of an off-the-shelf commercial stent graft system extended by an open stent configuration (Figure 1, Panel B). Pulses normalized immediately after completion of TEVAR and the patient recovered swiftly to leave hospital within four days without any residual malperfusion.
This patient's case demonstrates the feasibility of successfully managing an octogenarian patient with TEVAR to repair a type B dissection with ischemia. Furthermore, this case demonstrates reversal of signs and symptoms that classically herald an unfavorable prognosis,6-9 possibly setting the stage for longer survival with TEVAR than with medical management alone. Such a therapeutic goal, however, is difficult to prove in an octogenarian population considering that it required more than two years of follow-up to show a significant prognostic benefit of TEVAR over medical treatment alone in a randomized study comparing the two strategies.10,11 On the other hand, in the setting of complicated type B dissection, the survival benefit of TEVAR is highly likely to emerge sooner and, therefore, be clearly justified even in octogenarian patients; nevertheless, level one data may never be generated in this set of patients due to a relatively low incidence compared to other vascular conditions.
Conversely, octogenarian patients constitute a substantial and growing portion of patients both in the type B dissection and in type A scenario with one-third and one-quarter of cases, respectively. With an aging population, this portion is expected to increase further. Consequently, it is important for emergency physicians and cardiovascular specialists to familiarize themselves with clinical characteristics, emerging endovascular treatment options, and outcomes, particularly in the elderly subset of patients with aortic dissection. Interestingly in this elderly subset, the percentage of women is higher, probably as result of longer life expectancy12 and older age at the time of dissection.13 In addition, signs and symptoms of dissection may change with age and classic symptoms of ripping pain may be less frequently encountered as patients get older,14,15 probably associated with age-related physiological changes in pain perception.
When making therapeutic decisions regarding acute aortic dissection, age continues to play an important role in the selection of treatment options. Previous experience has shown that advanced age in the case of aortic dissection is an independent predictor of in-hospital mortality beside evidence of malperfusion and repetitive episodes of pain;14,16 others have communicated conflicting rates of death in the light of the high mortality without effective treatment, or in particular with open surgery.17-20 Such an age-dependent impact may be less dramatic in the setting of type B dissection with the therapeutic use of minimally invasive endovascular repair of the dissected aorta, avoiding the problems of cardiac arrest, cardiopulmonary bypass, ventilation, and weaning. Thus, limiting factors that apply for open surgery in type A and B dissection are completely avoided with TEVAR in type B dissection; in other words, the endovascular intervention itself is unlikely to impact survival negatively, even in the elderly population. This means that even octogenarians can qualify for TEVAR in distal dissection and benefit from aortic reconstruction rather than being left on blood pressure management without repair of the dissected aorta.
- Erbel R, Aboyans V, Boileau C, et al. 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). Eur Heart J 2014;35:2873-926.
- Hiratzka LF, Bakris GL, Beckman JA, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation 2010;121:e266-9.
- Fattori R, Cao P, De Rango P, et al. Interdisciplinary expert consensus document on management of type B aortic dissection. J Am Coll Cardiol 2013;61:1661-78.
- Clough RE, Nienaber CA. Management of acute aortic syndrome. Nat Rev Cardiol 2015;12:103-14.
- Koschyk DH, Nienaber CA, Knap M, et al. How to guide stent-graft implantation in type B aortic dissection? Comparison of angiography, transesophageal echocardiography, and intravascular ultrasound. Circulation 2005;112:I260-4.
- Nienaber CA, Kische S, Ince H, Fattori R. Thoracic endovascular aneurysm repair for complicated type B aortic dissection. J Vasc Surg 201;54:1529-33.
- Hanna JM, Andersen ND, Ganapathi AM, McCann RL, Hughes GC. Five-year results for endovascular repair of acute complicated type B aortic dissection. J Vasc Surg 2014;59:96-106.
- Fattori R, Montgomery D, Lovato L, et al. Survival after endovascular therapy in patients with type B aortic dissection: a report from the International Registry of Acute Aortic Dissection (IRAD). JACC Cardiovasc Interv 2013;6:876-82.
- Trimarchi S, Eagle KA, Nienaber CA, et al. Importance of refractory pain and hypertension in acute type B aortic dissection: insights from the International Registry of Acute Aortic Dissection (IRAD). Circulation 2010;122:1283-9.
- Nienaber CA, Rousseau H, Eggebrecht H, et al. Randomized comparison of strategies for type B aortic dissection: the INvestigation of STEnt Grafts in Aortic Dissection (INSTEAD) trial. Circulation 2009;120:2519-28.
- Nienaber CA, Kische S, Rousseau H, et al. Endovascular repair of type B aortic dissection: long-term results of the randomized investigation of stent grafts in aortic dissection trial. Circ Cardiovasc Interv 2013;6:407-16.
- National Center for Health Statistics. Health, United States, 2012, With Special Features on Emergency Care 2012. 2013 (CDC website) Available at: http://www.cdc.gov./nchs/data/hus/hus12.pdf. Accessed 12/5/2014.
- Meszaros I, Morocz J, Szlavi J, et al. Epidemiology and clinicopathology of aortic dissetion – a population-based longitudinal study over 27 years. Chest 2000;117:1271-8.
- Mehta RH, O'Gara PT, Bossone E, et al. Acute type a aortic dissection in the elderly: Clinical characteristics, management and outcomes in the current era. J Am Coll Cardiol 2002;40:685-692.
- Trimarchi S, Eagle KA, Nienaber CA, et al. Role of age in acute type A aortic dissection outcome: Report from the international registry of acute aortic dissection (IRAD). J Thorac Cardiovasc Surg 2010;140:784-9.
- Mehta RH, Bossone E, Evangelista A, et al. Acute type B aortic dissection in elderly patients: Clinical features, outcomes and simple risk stratification rule. Ann Thorac Surg 2004;77:1622-8.
- Hata M, Sezai A, Niino T, et al. Should emergency surgical intervention be performed for an octogenarian with type A acute aortic dissection? J Thorac Cardiovasc Surg 2008;135:1042-6.
- Biancari F, Vasques F, Benenati V, Juvonen T. Contemporary results after surgical repair of type A aortic dissection in patients aged 80 years and older: A systematic review and metaanalysis. Eur J Cardiothorac Surg 2011;40:1058-1063.
- Glower D, Fann J, Speier R, et al. Comparison of medical and surgical therapy for uncomplicated descending aortic dissection. Circulation 1990;82:IV39-46.
- Piccardo A, Regesta T, Pansini S, et al. Should octogenarians be denied access to surgery for acute type A aortic dissection? J Cardiovasc Surg 2009;50:205-12.
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