Aortic aneurysm and dissection are serious conditions with potentially life-threatening complications, necessitating timely recognition and intervention [1]. Risk factors for these conditions include age, hypertension, smoking, familial predisposition, connective tissue disorders, and specific genetic conditions [2,3]. Aortic aneurysm carries a critical risk of rupture, leading to severe hemorrhage and mortality [4]. The findings have revealed an overall incidence of thoracic aortic aneurysm (TAA) of 5.3 per 100,000 individuals/year and a prevalence of 0.16%, with a higher prevalence observed in autopsy-only studies [5]. Abdominal aortic aneurysms affect 2-8% of individuals aged 65 or older, while thoracic aortic aneurysms constitute 10-20% of all aortic aneurysms [6,7]. On the other hand, aortic dissection is relatively rare and has an estimated incidence of 2.9-3.5 cases per 100,000 person-years, primarily affecting individuals aged 50 or older, with a higher incidence in males [8,9,10]. Untreated aortic dissection can have mortality rates of 1-2% per hour in the initial 24-48 hours [11].

The limited data available on the prevalence and outcomes of aortic aneurysms in our region highlights the urgent need for further investigation. The lack of comprehensive information hinders our ability to develop region-specific management strategies and provide optimal care to patients.

This retrospective study aimed to evaluate the one-year mortality rates among patients with symptomatic aortic aneurysms and achieve specific objectives. The study aims to determine the overall one-year mortality rate in this patient population, identify factors associated with higher mortality rates, and investigate the potential association between post-treatment complications and mortality rates. Understanding the local state of aortic syndromes, risk factors, and mortality outcomes is crucial for healthcare professionals and policymakers to make informed decisions and allocate appropriate resources. By conducting this study, we aim to address the existing knowledge gap and provide valuable insights into the specific characteristics and challenges of aortic aneurysms in our region. This research will not only contribute to the advancement of medical knowledge but also serve as a strong motivation to improve patient outcomes and ultimately save lives.

Study design

This study was a retrospective cohort design using medical records and follow-up data of patients with symptomatic aortic aneurysms who were referred to Afshar and Shahid Sadoughi Hospitals in Yazd during 2017-2023.

Study Population

This study included patients who had symptomatic aortic aneurysms and had undergone diagnostic tests and treatment in this cardiac referral hospital during the mentioned year. Patients with incomplete medical records or out-of-hospital cardiac arrest or disease diagnosed by autopsy were excluded from the study.

Data Collection

In this study, we conducted a retrospective analysis of data obtained from medical records. To ensure a thorough understanding of the patient's medical profiles, various data points were extracted from the medical records. This included demographic information such as age, gender, and potentially other relevant factors. The clinical presentation of each patient was documented, providing insights into the symptoms and manifestations of the aortic aneurysm at the time of diagnosis.

Diagnostic imaging findings played a crucial role in this study. Specifically, CT scans of the patients' aortas were carefully reviewed by an imaging specialist who had undergone specialized training in interpreting CT scans. This additional review process aimed to confirm the accuracy of the initial diagnosis and ensure the reliable inclusion of patients in the study cohort.

In terms of treatment, the researchers documented the methods and approaches employed for managing symptomatic aortic aneurysms. This could include surgical interventions, endovascular procedures, or other therapeutic modalities. The information gathered on treatment methods allowed for an assessment of the interventions utilized in clinical practice and their potential impact on patient outcomes.

Furthermore, the researchers recorded any post-treatment complications that arose during the follow-up period. These complications could be related to the specific treatment received or could be inherent to the natural progression of the aortic aneurysm. By documenting and analyzing these complications, the study aimed to explore any potential associations between the occurrence of complications and the subsequent mortality rates.

To determine the mortality outcomes, the researchers relied on information provided in the death certificates of the patients who had passed away during the one-year follow-up period. The cause of death, as stated in the death certificates, was considered a reliable criterion for assessing mortality in the study population. This approach ensured consistency and objectivity in determining the outcomes and allow for comparisons across different patients.

Data Analysis

The data analysis for this study was conducted using the SPSS statistical software, specifically version 26. Descriptive statistics were employed to provide a summary of the patient characteristics and outcomes included in the dataset. To assess the relationships and associations between variables, appropriate statistical tests were applied. For quantitative variables, a two-sided independent t-test was utilized to compare means between different groups or conditions. On the other hand, qualitative variables were assessed using statistical tests such as the chi-square test, Fisher's exact test, and the Mann-Whitney U test. To identify the factors that were significantly related to mortality, multivariate regression analysis was performed. The forward stepwise method was employed to systematically remove any confounding factors and identify the most influential variables associated with death. In addition, we employed the Kaplan-Meier analysis to estimate the survival rate and assessed its significance using the Log Rank test. In terms of determining statistical significance, a significance level of 0.05 was considered.

Ethical Considerations

The present study adhered to ethical guidelines and acquired approvals from the institutional review board (IR.SSU.MEDICINE.REC.1402.264). Stringent measures were implemented to uphold patient confidentiality and privacy throughout the study. To ensure anonymity, patient data was appropriately anonymized during the process of analysis and reporting.

A total of 150 patients with a confirmed diagnosis of aortic aneurysm were included in this study. Among these patients, 76 individuals were identified as having true aneurysms, while 74 patients were classified as having false aortic aneurysms. The dataset derived from these patients formed the basis for the subsequent analyses conducted in this study.

The mean age of patients with true (symptomatic) aortic aneurysms was 60.8 ± 18.2 years, while for those with false (asymptomatic) aortic aneurysms, it was 58.9 ± 18.3 years. Among patients with true aortic aneurysms, 61 (80.3%) were male and 15 (19.7%) were female. In the dissectiongroup, 54 (73.0%) were male and 20 (27.0%) were female. Various risk factors were assessed in patient’s withtrue aortic aneurysm and dissection. The prevalence of trauma, systemic hypertension, positive family history, cardiac surgery, Marfan syndrome, pregnancy, aortic coarctation, and prior aneurysm repair were compared between the two groups. None of these risk factors showed statistically significant differences between the two groups, except for Marfan syndrome (p = 0.004).

The presentation of patient’s withtrue aortic aneurysm and dissection was evaluated in terms of acute heart failure (HF), shock, and cardiac arrest. The incidence of shock and cardiac arrest was significantly higher in the dissectiongroup compared to the true aortic aneurysm group (p < 0.001, p = 0.077, respectively).

Chest pain, abdominal pain, dyspnea, and asymmetric pulse were more commonly observed in patients with true aortic aneurysms compared to the dissectiongroup (p < 0.05). Similarly, AI murmur was significantly more prevalent in the true aortic aneurysm group (p < 0.001). The true aortic aneurysm group had significantly higher systolic, diastolic, and mean blood pressures compared to the dissectiongroup (p = 0.003, p = 0.027, p = 0.006, respectively).

Sinus tachycardia, ST depression, LBBB, and nonspecific ST-T changes were more frequently observed in patients with true aortic aneurysms compared to the false group (p < 0.05). In contrast, sinus bradycardia and ST elevation were more prevalent in the dissection group (p = 0.004).

Chest radiographic findings including mediastinum widening, cardiomegaly, and pleural effusion were compared between patients with true aortic aneurysm and dissection. The presence of mediastinum widening was significantly higher in the dissection group (p < 0.001).

The true aortic aneurysm group had a significantly higher prevalence of pericardial effusion compared to the false group (p = 0.002). There were no statistically significant differences in the occurrence of aortic insufficiency or bicuspid aortic valve between the two groups.

There were no statistically significant differences in LVEF, PASP, or aneurysm size between the two groups (p > 0.05).

In terms of the site of the aneurysm, thoracic ascending involvement was more frequently observed in the dissection group, while thoracic descending aneurysms were more common in the true group (p = 0.001).

There were no statistically significant differences in the utilization of medical, surgical, or endovascular treatment between the two groups (p > 0.05).

The duration of ICU stay was significantly shorter in the true aortic aneurysm group compared to the false group (p = 0.04). However, there were no significant differences in the duration of hospital stay between the two groups (p = 0.228) [Table 1].

Table 1: Baseline Characteristics of Aortic Aneurysm According To Type of Aneurysm in the Study Population.

The occurrence of bleeding as a complication was observed in 6.6% of true aneurysm cases and 20.3% of dissection cases. Cardiac tamponade occurred in 2.6 of true aneurysm cases and 12.2% of dissection cases. The incidence of heart failure as a complication was 9.2% in true aneurysm cases and 18.9% in dissection cases.

Acute renal failure occurred in 7.9% of true aneurysm cases and 9.5% of dissection cases.

Limb ischemia was observed in 9.2% of true aneurysm cases and 6.8% of dissection cases.

None of the true aneurysm cases experienced myocardial infarction as a complication, while 6.8% of dissection cases did.

Overall, 14.5% (11 out of 76) of true aneurysm cases resulted in death, whereas a significantly higher percentage, 51.4% (38 out of 74), of dissection cases led to death [Table 2].

Table 2: Comparison of Fatal and Nonfatal Complications of Aortic Aneurysm in the Study Population.

The comparison of two groups in terms of the relationship between variables and death showed that based on the odds ratios and their corresponding p-values, complications, unstable presentation, type of aneurysm (dissection), and age greater than or equal to 60 are all significantly associated with death. These variables were important factors in predicting the occurrence of mortality during one year [Tables 3, 4].

Table 3: Univariate Analysis of Variables for Mortality According To Type of Aneurysm.

Table 4: Predictors of One-Year Mortality in the Study Population.

The survival analysis conducted in this study yielded significant results regarding the occurrence of death within one year between the true aneurysm group and the dissection group (p=0.000). Specifically, the dissection group demonstrated a significantly higher incidence of mortality compared to the true aneurysm group.

Upon closer examination of the temporal distribution of deaths within each group, distinct patterns emerged. In the dissection group, a majority of deaths transpired within the initial month following diagnosis, indicating a more rapid disease progression and potentially more severe complications associated with false aneurysms. Conversely, the analysis of survival curves in the true aneurysm group displayed a gradual decline in survival rates throughout the one-year follow-up period. The slope of the survival curves exhibited a gentle downward trend, signifying a gradual decrease in the probability of survival as time advanced [Figure 1].

Figure 1: Kaplan - Meier Curve Illustrating One Year Survival in Different Categories of Aortic Aneurysm (True Aneurysm Vs Dissection).

Figure 2: Kaplan - Meier Curve Illustrating One Year Survival of Patients According to Aneurysm Related Complications (Yes;Complicated ,No:Uncomplicated Aneurysm).

However, it is important to note that the survival analysis did not uncover any statistically significant differences in one-year mortality rates about the type of treatment or the location of the aortic aneurysm [Figures 2, 3, 4].

Figure 3:  Kaplan - Meier Curve Illustrating One Year Survival Aneurysm Patients According to Clinical Presentation (Hemodynamicaly Stable Vs Unstable).

Figure 4: Kaplan - Meier Curve Illustrating One Year Survival Aneurysm Patients According to the Age Categories (Age>=60 Vs <60 Yr).

This study provides a comprehensive review of the characteristics of patients with aortic aneurysms, including both true aneurysms and dissections. It covers various aspects such as demographic and clinical attributes, imaging techniques, treatment approaches, and a thorough 12-month follow-up to determine mortality rates and predictive factors. By conducting a comparative analysis of these variables among patients in a retrospective cohort study, we have successfully identified the differences and similarities between these significant manifestations of aortic pathology.

Our study reveals a notable association between Marfan syndrome and dissections of the aorta, which is consistent with previous research on aortic dissection, including the International Registry of Acute Aortic Dissection (IRAD). This registry recognizes Marfan syndrome as a recognized risk factor for aortic dissection [12]. Similarly, investigations into true aortic aneurysms, such as the ADAM study, have identified risk factors such as advanced age, male gender, smoking, and hypertension [13].

We have shed light on the characteristic symptoms of dissections of the aorta, including chest pain, abdominal pain, dyspnea, and asymmetric pulses. These findings align with prior studies on aortic dissection, such as the IRAD registry, which consistently highlights chest pain as the most common symptom [12]. Likewise, studies on true aortic aneurysms have identified symptoms such as abdominal or back pain in affected individuals [14].

Our study's radiographic findings, such as mediastinal widening and pericardial effusion in cases of dissections of the aorta, provide valuable insights. These findings can be compared to studies on aortic dissection, where mediastinal widening serves as an important diagnostic criterion in medical imaging. However, it is important to note that specific radiographic findings may differ between aortic aneurysms and aortic dissection due to variations in underlying pathological processes [15,16].

In terms of complications and outcomes, our research demonstrates a higher incidence of hemorrhage, cardiac tamponade, heart failure, acute kidney injury, limb ischemia, and mortality with dissections of the aorta compared to true aortic aneurysms. These findings are consistent with studies on aortic dissection, such as the IRAD registry, which emphasizes the prevalence of complications like cardiac tamponade, heart failure, and increased mortality rates among affected patients. Similarly, investigations into true aortic aneurysms, including the PA study, have examined outcomes such as aneurysm growth, rupture, and mortality [12,14].

The current study aimed to examine the factors associated with mortality in patients with symptomatic aortic aneurysm and dissection, without regard to the specific treatment interventions employed. Several variables were assessed, and among them, age, unstable presentation, type of aneurysm, and aneurysm-related complications emerged as significant predictors of mortality in this particular patient cohort.

In our study, aneurysm-related complications during hospitalization emerged as the most robust indicator of mortality.

The impact of age on mortality in aortic aneurysm and dissection has been extensively examined in prior research. Advanced age has consistently been associated with a higher risk of complications and poorer outcomes. This association is likely attributed to age-related physiological changes, diminished physiological reserves, and the presence of multiple comorbidities, which collectively contribute to an increased susceptibility to adverse events and subsequent mortality [17,18].

The size of the aneurysm has emerged as another important predictor of mortality. Larger aneurysms have consistently been associated with an elevated risk of rupture, leading to life-threatening hemorrhage and significantly higher mortality rates. Clinical thresholds, such as the widely employed 5.5-centimeter threshold for abdominal aortic aneurysms, have been established to identify the increased risk associated with larger aneurysm sizes [19]. The results of our study indicate that the size of the aneurysm does not have predictive value in determining mortality outcomes following aneurysm repair interventions.

It should be noted that the extent of aneurysm expansion is also known as a significant predictor of mortality. Rapid expansion of an aneurysm indicates increased instability and a higher likelihood of rupture. Consequently, patients with aneurysms exhibiting a rapid expansion rate require close monitoring and may be candidates for surgical intervention to mitigate the risk of rupture and subsequent mortality [20].

Our study identified a significant relationship between aneurysm categories and mortality following treatment, with the category of dissection emerging as a particularly strong predictor of death. Previous research has demonstrated that the specific type of aortic dissection has a greater impact on the mortality rate. Stanford Type A dissections, involving the ascending aorta, have been associated with a higher risk of mortality compared to Type B dissections that are limited to the descending aorta. Urgent surgical intervention is typically warranted for Type A dissections due to the potential for catastrophic complications [21,22].

Our study did not find that comorbidity serves as an additional significant predictor of mortality in aortic aneurysm and dissection. However, it is important to note that comorbidities play a significant role in predicting mortality in this patient population. Previous research has consistently demonstrated that conditions such as hypertension, coronary artery disease, chronic kidney disease, chronic obstructive pulmonary disease, and other comorbidities are associated with higher mortality rates. These underlying conditions contribute to an increased risk of cardiovascular events, organ dysfunction, and postoperative complications, ultimately impacting patient outcomes [22,23].

While our study did not find evidence supporting Marfan syndrome as a risk factor for mortality following aneurysm treatment, Patients with connective tissue disorders, such as Marfan syndrome, may exhibit higher mortality rates due to the inherent weakness of the aortic wall [24]. Recent studies have consistently reported a high success rate, nearing 100%, for aneurysm surgery in individuals diagnosed with Marfan syndrome [25]. Accordingly, meticulous monitoring and timely surgical intervention are imperative for individuals with these conditions to mitigate the risk of aortic dissection and associated mortality [26].

In our study, we identified hemodynamic instability at the time of admission as a significant predictor of mortality following hospitalization.

Hemodynamic instability, characterized by hypotension or shock upon presentation, has been identified as a significant predictor of mortality [27]. This clinical manifestation indicates a more severe disease state and necessitates immediate medical intervention to stabilize the patient and prevent further complications.

Although delayed diagnosis and treatment have been recognized as factors contributing to increased mortality rates in aortic aneurysm and dissection nevertheless our analysis did not show a significant factor of mortality. Early recognition, prompt medical evaluation, and timely surgical intervention must be critical in optimizing outcomes and reducing mortality in these conditions. It is noteworthy to mention that in our study, the logistic regression analysis did not yield separate models for predicting one-year mortality in aortic aneurysm cases. This was primarily due to the absence of any variable identified as a significant predictor of death specifically in true aortic aneurysm cases. Consequently, the model presented in our study is intended for the prediction of mortality in cases of   aortic dissection.

It is important to emphasize that despite the lack of predictive variables for mortality in true aortic aneurysm cases, our study underscores the need for further exploration of potential factors that may influence mortality outcomes within this particular population.

Limitations

This study has several limitations. Firstly, the retrospective design and reliance on historical data introduce potential biases and compromise the reliability of the findings. Secondly, drawing data from a single healthcare facility limits the generalizability of the results to broader populations. Thirdly, the small sample size raises concerns about statistical power and the ability to detect significant associations. Fourthly, selection bias may affect the representativeness of the study population. Additionally, the 12-month follow-up period may not capture long-term outcomes accurately. The study also fails to account for treatment variability and lacks comprehensive information on comorbid conditions. Confounding factors such as socioeconomic status and lifestyle factors are not adequately controlled for. The absence of subgroup analysis limits understanding of variations within different patient groups. Lastly, the limited generalizability of the findings to diverse populations and healthcare systems should be considered.

The present study reaffirms the findings of previous research by establishing age, unstable presentation, type of aneurysm, and comorbidity as strong predictors of death in symptomatic aortic aneurysm and dissection, regardless of the treatment modalities employed. These predictors underscore the significance of timely intervention and comprehensive management strategies to improve patient outcomes and mitigate mortality risks. Future research and clinical efforts should continue to explore innovative approaches for risk stratification and targeted interventions in aortic aneurysm and dissection, aiming to further enhance patient care and outcomes.

It is crucial to recognize that when comparing aortic dissection and true aortic aneurysm, one must consider the distinct features and underlying pathophysiological mechanisms of these conditions. Aortic aneurysm involves the dilation of the aortic wall, while aortic dissection is characterized by a tear in the aortic wall, leading to the separation of its layers. Despite these differences, there are overlapping aspects related to risk factors, clinical presentation, radiographic findings, and complications between the two conditions.

Acknowledgments

We extend our sincere gratitude to the dedicated staff of the IT department, archives, and CT angiography department at Afshar Hospital for granting us access to the medical records of the patients included in this study. Their valuable assistance and cooperation were instrumental in the successful completion of our research.

Conflict of Interest

The authors declare there is no conflict of interest.

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