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Object: Vertebrobasilar dissecting aneurysms (VBDAs) are known to have a poor natural history with high rates of re-bleeding and mortality. There is a strong relation between hyperhomocysteinemia (HHcy) and cerebrovascular disease; we perform a retrospective study within the male of Chinese Han population to explore the association between HHcy and VBDAs., Methods: Eighty-eight male patients with VBDA and Eighty-one male control subjects were evaluated for their serum total homocysteine levels. With multiple logistic regression analysis, the association between HHcy and the risk of VBDAs was estimated. Interaction and stratified analyses were conducted according to age, BMI, smoking status, drinking status, and chronic disease histories. The two-piecewise linear regression model examined the threshold effect., Results: The multivariate logistic regression analyses revealed a significant association between HHcy and VBDAs (odds ratio (OR) = 2.62; 95% confidence interval (CI), 1.02-6.71) after adjusting for classical vascular risk factors. The relationship was stable in all subgroup analysis. The interactive role was not found in the association between HHcy and VBDAs for the potential risk factor., Conclusions: In summary, our study provides evidence that HHcy can increases the risk of VBDAs in the male Han Chinese population. Further researches with appropriate study designs including sex differences and aneurysm types are needed to verify this association.

Background: We assessed the effect of race and ethnicity on presentation severity and postoperative outcomes in those with abdominal aortic aneurysms (AAAs), carotid artery stenosis (CAS), peripheral arterial disease (PAD), and type B aortic dissection (TBAD)., Methods: MEDLINE, Embase, and Cochrane Central Register of Controlled Trials from inception until December 2020. Two reviewers independently selected randomized controlled trials and observational studies reporting race and/or ethnicity and presentation severity and/or postoperative outcomes for adult patients who had undergone major vascular procedures. They independently extracted the study data and assessed the risk of bias using the Newcastle-Ottawa scale. The meta-analysis used random effects models to derive the odds ratios (ORs) and risk ratios (RRs) and their corresponding 95% confidence intervals (CIs). The primary outcome was presentation severity stratified by the proportion of patients with advanced disease, including ruptured vs nonruptured AAA, symptomatic vs asymptomatic CAS, chronic limb-threatening ischemia vs claudication, and complicated vs uncomplicated TBAD. The secondary outcomes included postoperative all-cause mortality and disease-specific outcomes., Results: A total of 81 studies met the inclusion criteria. Black (OR, 4.18; 95% CI, 1.31-13.26), Hispanic (OR, 2.01; 95% CI, 1.85-2.19), and Indigenous (OR, 1.97; 95% CI, 1.39-2.80) patients were more likely to present with ruptured AAAs than were White patients. Black and Hispanic patients had had higher symptomatic CAS (Black: OR, 1.20; 95% CI, 1.04-1.38; Hispanic: OR, 1.32; 95% CI, 1.20-1.45) and chronic limb-threatening ischemia (Black: OR, 1.67; 95% CI, 1.14-2.43; Hispanic: OR, 1.73; 95% CI 1.13-2.65) presentation rates. No study had evaluated the effect of race or ethnicity on complicated TBAD. All-cause mortality was higher for Black (RR, 1.23; 95% CI, 1.01-1.51), Hispanic (RR, 1.90; 95% CI, 1.57-2.31), and Indigenous (RR, 1.24; 95% CI, 1.12-1.37) patients after AAA repair. Postoperatively, Black (RR, 1.54; 95% CI, 1.19-2.00) and Hispanic (RR, 1.54; 95% CI, 1.31-1.81) patients were associated with stroke/transient ischemic attack after carotid revascularization and lower extremity amputation (RR, 1.90; 95% CI, 1.76-2.06; and RR, 1.69; 95% CI, 1.48-1.94, respectively)., Conclusions: Certain visible minorities were associated with higher morbidity and mortality across various vascular surgery presentations. Further research to understand the underpinnings is required., (Copyright © 2022 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Management of uncomplicated type B aortic dissection (TBAD) has traditionally been aggressive medical therapy. Recent studies brought about a paradigm shift with evidence to suggest benefits from early endovascular intervention to a high risk subgroup of acute uncomplicated TBAD patients., Aims: We aim to review the effects of aortic remodeling in Asian patients with TBAD with and without endovascular intervention, including maximal aortic diameter, true lumen diameter, and false lumen thrombosis., Methods: This is a single-center retrospective study of a prospective database. Patients who presented to our institution with acute TBAD from January 2008 to December 2015 (n = 44) were evaluated. Eighteen percent (8 patients) presented with complicated TBAD and underwent emergency thoracic endovascular aortic repair (TEVAR) while the remaining 82% (36 patients) were treated with optimal medical therapy (OMT)., Results: Six patients under the conservative arm crossed over to elective TEVAR after 6 weeks because of interval radiological progression of disease. There was no significant difference in the baseline demographics of the TEVAR group and the OMT group. At 24 months, mean maximal aortic diameter difference was -7.7 mm and +1.9 mm (P = 0.077), mean true lumen diameter difference was +10.0 mm and +2.6 mm (P = 0.049), and false lumen thrombosis was 100% and 20% (P = 0.012) for TEVAR and OMT, respectively. Kaplan-Meier analysis showed no significant difference in mortality between the 2 groups at 30 days and 2 years., Conclusions: Within an Asian population with TBAD, TEVAR with OMT has a significant positive effect on aortic remodeling, compared with OMT-only management., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Aortic dissection is a life-threatening condition frequently requiring emergency surgery. Key risk factors include hypertension and aortopathy syndromes; however, possible ethnic associations and differences in presentation and outcomes are less well established. We compared characteristics and outcomes of type A aortic dissection surgery by ethnicity., Methods: Consecutive patients having type A aortic dissection surgery at Auckland City Hospital March 2003-March 2017 were divided into three ethnic groups: Māori, Pasifika and 'other', and analysed for characteristics, presentation and outcomes., Results: Among 327 patients, 45 (14%) were Māori, 91 (28%) were Pasifika Islander and 191 (58%) were other ethnicities. Mean age was lowest for Māori 51+/-12 years, then Pasifika 56+/-12 and other ethnicities 63+/-13 (P<0.001). Māori and Pasifika ethnicities had higher body mass index, more hypertension, dyslipidaemia and smoking, but lower proportion presenting in critical pre-operative state. Operative mortality occurred in 5 (11%), 18 (20%) and 42 (22%) for Māori, Pasifika and other ethnicities (P=0.258). Pasifika had higher age-standardised operative mortality standardised mortality ratio 6.00, 95% confidence interval 3.67-9.30 than 'other' ethnicities, while Māori had higher age-standardised late mortality 5.71, 2.90-10.2 respectively, and the latter association persisted in multivariable analysis. Critical pre-operative state and malperfusion syndrome independently predicted operative mortality., Conclusion: Māori and Pasifika patients were younger and present less unwell with type A aortic dissection, but had higher prevalence of cardiovascular risk factors. They had higher age-standardised late and operative mortality respectively, suggesting that aggressive management and risk factor control are critical for these patients., Competing Interests: Nil.

Objective: The objective of this study was to evaluate the difference in outcomes after endovascular intervention in patients with complicated type B aortic dissection (TBAD) based on ethnicity and blood pressure control., Methods: Between 2012 and 2016, there were 126 patients who underwent endovascular procedures for complicated TBAD at a single-institution quaternary referral center. Patients self-identified as African American (n = 53), white (n = 70), and Asian (n = 3). African American and white patients were compared on a number of variables, including age, ethnicity, insurance type, blood pressure, comorbidities, number of previous interventions, and number of antihypertension medications they were taking before intervention. Primary outcomes were survival and need for reintervention., Results: Kaplan-Meier estimates for survival for African Americans vs whites were 94% vs 89%, 91% vs 83%, 89% vs 79%, and 89% vs 76% at 30 days, 1 year, 3 years, and 5 years, respectively (P = .05). African Americans were younger overall (52.5 ± 11 years) vs whites (63.7 ± 14.7 years; P < .0001). African Americans required a significantly greater number of reinterventions (P = .007). They also had higher rates of chronic kidney disease (P = .01), smoking (P = .03), and cocaine use (P = .02) and were more likely to be on Medicaid (P = .02). Hypertension was poorly controlled in both groups, with the percentage of patients with uncontrolled hypertension (systolic >140 mm Hg) preoperatively, postoperatively, and 30 days after intervention at 32%, 32%, and 39%. There was no significant difference between the cohorts in uncontrolled hypertension preoperatively (P = .39) or postoperatively (P = .63). However, more African Americans had uncontrolled hypertension at 30 days (African Americans, 49%; whites, 31%; odds ratio, 2.1; P = .09). African Americans were taking a greater number of antihypertension medications at presentation than whites (P = .01) and specifically had higher use rates of beta blockers (P = .02), diuretics (P = .02), and angiotensin-converting enzyme inhibitors (P = .04)., Conclusions: African Americans with TBAD present at a younger age than their white counterparts do and have a survival advantage up to at least 5 years. However, African Americans have a higher rate of reintervention that is probably associated with poor blood pressure control despite taking more antihypertension medications both before and after the repair. It appears that optimal medical therapy is difficult to achieve in all groups. More aggressive medical management is needed, particularly more so in African Americans, which may in turn decrease the number of interventions and potentially improve long-term survival., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Chronic inflammation may be involved in pathogenesis of thoracic aortic dissection (TAD). Tumor necrosis factor-alpha (TNF-α) is a proinflammatory cytokine that plays an important role in pathological TAD progression. In this study, we determined wether genetic variants of TNF-α were associated with TAD., Methods: Frequency distributions of TNF-α promoter polymorphisms (-1031C/T,-857C/T,-308G/A, and -238G/A) were determined by direct sequencing. TNF-α plasma levels were measured by enzyme-linked immunosorbent assay. Plasma levels of TNF-α mRNA in peripheral-blood mononuclear cells were analyzed by real-time quantitative polymerase chain reaction amplification., Results: We found the TNF-α promoter -857C/T polymorphism is associated with disease progression susceptibility in TAD patients. The CC homozygote of TAD patients had a significantly higher risk of TAD than did T allele carriers (P< 0.05). Plasma TNF-α concentrations were also significantly higher in TAD patients than control subjects (P<0.05), and CC genotype carriers showed increased TNF-α levels compared with T allele carriers (P<0.05). Moreover, peripheral-blood mononuclear cells carrying the CC genotype showed increased TNF-α mRNA levels compared with cells carrying the T allele., Conclusions: The -857C/T polymorphism of TNF-α promoter plays a role in the genetic variation underlying susceptibility of individuals to TAD progression. The CC genotype is associated with increased TNF-α expression in TAD patients, and may be an independent predictive factor for TAD.

Objective: To evaluate racial differences in the burden of aortic dissection., Design: Retrospective analysis of a comprehensive state-wide inpatient database., Setting: Acute care hospitals in the state of Maryland, 2009 - 2014., Participants: All hospitalized adults with aortic dissection (AD), stratified by race., Main Outcome Measures: Statewide and county-level population adjusted hospitalization rates, access to specialty aortic care, and mortality., Results: Of 3,719,412 admissions to Maryland hospitals during the study period, 3,190 had AD (.09%; 1665 White, 1525 non-White). Non-White race was more common in patients with AD than without (48% vs. 41%, P<.0001). Adjusted for statewide demographics, admission for AD was 1.4 times more common among non-Whites (11 vs. 8 per 100,000, P<.0001). Non-White race was an independent risk factor for AD admission (OR 1.5, 95% CI 1.4 - 1.7). Among patients with AD, non-Whites were younger and more often female, but had similar or lower rates of cardiovascular comorbidities. Non-White race was not associated with decreased access to care or increased mortality., Conclusion: Hospitalization for AD is more common among non-Whites, who develop AD at younger ages despite fewer comorbidities. While clinical correlates are limited from this dataset, this may reflect more severe pathophysiology related to clinical or socioeconomic factors among non-Whites. Further study is warranted to better define this disparity and identify high-risk subgroups who may benefit from aggressive primary prevention.

Spontaneous cervico-cerebral artery dissection (CCAD) is a common condition found among young patients with ischemic stroke. We examined the possible association between the polymorphism of methylenetetrahydrofolate reductase (MTHFR)-C677T and the gene mutation in transforming growth factor beta receptor II (TGFBR2) in a cohort of CCAD patients. One-hundred CCAD cases (65 males; mean age: 38.08 ± 10.68 years) and 100 matching controls were included. Ancestry informative markers (AIMs) were used to increase internal validity of the genetic analysis. Genotypes of the C677T polymorphism in the MTHFR gene were determined by polymerase chain reaction and restriction fragment length polymorphism; direct sequencing was used for a mutation analysis of the TGFBR2 gene. Associations were evaluated using a multivariate statistics, and Hardy-Weinberg equilibrium was analyzed. We also incorporated our data into a meta-analysis of the MTHFR-C677T. Sixty-three patients presented with vertebral and 37 with carotid artery dissection. Ancestry markers found a call rate on each over 95 %. All AIMs did not deviate from Hardy-Weinberg equilibrium (p > 0.05). The homozygous TT genotype was more frequent in cases (OR 2.04, CI 95 % 1.53-2.72, p = 0.005), whereas no significant difference was found on heterozygous CT genotype. TGFBR2 mutation was not present in our samples. In the meta-analysis of MTHFR/C677T variant, a total 613 cases and 1547 controls were analyzed; we found a moderate association for the recessive model genotype (OR 2.04, CI 95 % 1.53-2.72; p = 0.342; Z = 4.83; I (2) = 11.3). This study supports a positive association between the MTHFR-C677T polymorphism and genetically confirmed Mexican mestizo CCAD patients.

Background: It is well-recognized that diabetes represents a powerful independent risk factor for cardiovascular diseases. However, very few studies have investigated the relationship between diabetes and risk of aortic dissection (AD)., Aim: The aim of this case-control study was to evaluate the association between diabetes and risk of AD in Chinese population., Methods: A hospital-based case-control study, consisting of 2160 AD patients and 4320 controls, was conducted in a Chinese population. Demographic, clinical characteristics and risk factors were collected. Diabetes rate of patients with overall AD, Stanford type A AD and type B AD group was compared with that of corresponding matched control groups. Logistic regression analysis was used to estimate the odds ratios (OR) and 95% confidence intervals (95% CI) for relationship between diabetes and AD risk., Results: The prevalence of diabetes was lower in AD cases than that of control subjects, whether it is the overall AD, type A AD or type B AD group (4.7% vs. 10.0%, 2.9% vs. 8.8%, 5.9% vs. 10.9%, all P<0.001). Furthermore, in multivariate model, diabetes was found to be associated with lower AD risk, which not only applies to the overall AD (OR = 0.2, 95%CI: 0.15-0.26), but also type A AD (OR = 0.12, 95% CI: 0.07-0.20) and type B AD (OR = 0.25, 95%CI: 0.18-0.33)., Conclusions: We observed the paradoxical inverse relationship between DM and risk of AD in the Chinese population. These results suggest diabetes may play a protective role in the development of AD. However, further studies are needed to enrich related evidence, especially with regard to underlying mechanisms for these trends.

Objective: To establish a systematic registry of aortic dissection in China, assess the clinical features of Chinese patients with acute aortic dissection (AAD), and compare our results with the data published by the International Registry of Acute Aortic Dissection (IRAD)., Methods: We established the first Registry of Aortic Dissection in China (Sino-RAD) in 2011. Then we evaluated 1003 patients with AAD in Sino-RAD and compared our results with those reported by IRAD., Results: Compared with IRAD, the patients with AAD in Sino-RAD were significantly younger. Also, the ratio of male patients in Sino-RAD was significantly greater for the total cohort and the type A and B cohorts. The overall in-hospital mortality was 10.3% in Sino-RAD. For type A dissection, more patients in Sino-RAD received medical treatment and fewer received surgical treatment. The overall mortality, mortality of medical treatment, and mortality of surgical treatment was lower in Sino-RAD. In type B dissection, fewer patients in Sino-RAD received medical and surgical treatment and more received endovascular treatment., Conclusions: The first Sino-RAD, including 15 large cardiovascular centers throughout China, was established. Our data were compared with those reported by IRAD. We found that, compared with Western populations, Chinese patients with AAD showed 6 differences, including earlier onset, more male patients, a low incidence of hypertension, a low incidence of chest pain, a high incidence of back pain, great differences in the choice of therapeutic strategies, and relatively low in-hospital mortality., (Copyright © 2014. Published by Elsevier Inc.)

Purpose: To characterize type A aortic dissection (TAAD) in the Chinese population using high-resolution computed tomography (CT) and explore potential candidacy for endovascular repair of TAAD., Methods: The imaging studies and medical records of all 302 patients presenting with TAAD at two Chinese hospitals from 2010 to 2013 were reviewed. Of these, 221 patients were excluded because of missing/inadequate preoperative CT scans. The remaining 91 patients (64 men; mean age 51.1±7.5 years) had CT data adequate to assess anatomical suitability for endovascular treatment. Entry tears were identified using multiplanar reconstructions, while morphological measurements were based on a centerline of flow (CLF) technique. Suitability for endovascular treatment was based on a proximal landing zone ≥20 mm long, a true lumen aortic diameter ≤38 mm, and a total aortic diameter ≤46 mm; no coronary bypass grafts originating from the ascending aorta; no malfunctioning aortic valve; and good cerebral and cardiac perfusion., Results: In the 91 patients, the precise location of the primary proximal entry tear could be identified in only 34 (37.4%) patients; in these patients, the identifiable intimal tears were located 36.4±41.0 mm distal to the closest coronary artery. The CLF was successfully generated in the CT scans of all patients; the mean lumen and total aortic lumen diameters at the entry tear level were 37.6±6.3 and 44.3±13.3 mm, respectively. Based on the CT measurements, stent-graft repair would have been anatomically feasible in 35 (38.5%) patients. No proximal landing zone (n=23), large aortic diameter (n=15), abnormal aortic valve (n=10), previous coronary bypass graft surgery (n=5), and poor cerebral and cardiac perfusion (n=3) were obstacles that affected the suitability for this treatment., Conclusion: Based on high-resolution CT scans, our pilot study suggested that 38% of Chinese patients with TAAD could potentially be treated by stent-grafting based on the anatomical characteristics of the proximal dissection.

Aim: Thoracic aortic dissection (TAD) is the most common life-threatening disorder, and a shifted balance of matrix metalloproteinases (MMPs) and tissue inhibitors of metalloproteinases (TIMPs) is involved in TAD pathogenesis. The aim of this study was to evaluate the association of 4 single-nucleotide polymorphisms (SNPs) in MMP-9 and TIMP-3 genes with TAD risk in Chinese Han population., Methods: A total of 206 Chinese patients with TAD and 180 controls were included in this study. Four SNPs (rs3918249, rs2274756, rs9609643 and rs8136803) were genotyped using high-throughput MALDI-TOF mass spectrometry. Allele and genotype association analyses were conducted using PLINK., Results: All the 4 SNPs resulted in Hardy-Weinberg equilibrium in patients and controls. The G allele frequency for the MMP-9 SNP rs2274756 was significantly higher in female TAD patients than in female controls (P=0.0099). Moreover, after adjusting for traditional cardiovascular risk factors (sex, age, hypertension, dyslipidemia, diabetes and smoking habit), the rs2274756 polymorphism (odds ratio: 0.30; 95% confidence interval: 0.11 to 0.79, P=0.015) resulted in an independent susceptibility factor for TAD in females. No associations were found between the other SNPs and TAD., Conclusion: The results provide strong evidence for an association between MMP-9 SNP rs2274756 and female TAD risk in Chinese Han population.

Background: Few data exist on race-related differences in acute aortic dissection patients., Methods: We evaluated black (n = 189, 14%) or white (n = 1165, 86%) patients (mean age 62.8 ± 15.3 years; 36.4% women) enrolled in 13 US centers participating in the International Registry of Acute Aortic Dissection. We excluded patients of other racial descent., Results: Type B acute aortic dissection was more frequent in the black cohort (52.4% vs 39.3%, P = .001). Black patients were younger (mean age 54.6 ± 12.8 years vs 64.2 ± 15.2 years, P <.001) and more likely to have a history of cocaine abuse (12% vs 1.6%, P <.001), hypertension (89.7% vs 73.9%, P <.001), and diabetes (13.2% vs 6.4%, P = .001). Conversely, they were less likely to have bicuspid aortic valve (1.8% vs 5.8%, P = .029), iatrogenic dissection (0.5% vs 4.5%, P = .010), and prior aortic dissection repair (7.7% vs 12.8%, P = .047). Presenting features were similar except for more abdominal pain (44.6% vs 30.6%, P <.001) and left ventricular hypertrophy on echocardiogram (44.2% vs 20.1%, P <.001) in blacks. Management was similar. Hypotension/shock/tamponade was less common (7.6% vs 20.1%, P <.001), whereas acute kidney failure was more common (41.0% vs 21.7%, P <.001) in blacks. Mortality was similar in-hospital (14.3% vs 19.1%, P = .110, odds ratio 0.704, 95% confidence interval 0.457-1.085) and at 3 years postdischarge, as evaluated by Kaplan-Meier survival analysis (22.0% vs 14.3%, P = .224, SE = 0.062 and 0.018)., Conclusions: Our study shows differences in type, etiology, and presentation of blacks and whites with acute aortic dissection, yet similar mortality for these cohorts., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Excessive activation of the transforming growth factor beta signaling pathway and disorganized cellular skeleton caused by genetic mutations are known to be responsible for the inherited thoracic aortic aneurysms and dissections (TAAD), a life-threatening vascular disease. To investigate the genotype-phenotype correlation, we screened genetic mutations of fibrillin-1 (FBN1), transforming growth factor-β receptor-1 (TGFBR1) and transforming growth factor-β receptor-2 (TGFBR2) for TAAD in 7 affected families and 22 sporadic patients. Of 19 potential mutations identified in FBN1, 11 appeared novel while the others were recurrent. Two mutations were detected in TGFBR2. Eight patients carried no mutation in either of these genes. Characterization of FBN1 c.5917+6T>C in transfected HEK293 cells demonstrated that it caused skipping of exon 47, leading to the loss of the 33th calcium binding epidermal growth factor-like domain associated with Marfan syndrome. Compared with exon 46, skipping of 47 did not cause patients ectopia lentis in all carriers. To correlate genotypes with phenotypes in different human ancestries, we reviewed the published mutational studies on FBN1 and found that the probability of cardiovascular defects were significantly increased in Chinese patients with premature termination codon or splicing mutations than those with missense mutations (91.7 % vs 54.2 %, P = 0.0307) or with noncysteine-involved point mutations than those with cysteine-involved mutations (88.9 % vs 33.3 %, P = 0.0131). Thus, we conclude that exon 47 skipping of FBN1 leads preferentially to cardiovascular defects and human ancestries influence genotype-phenotype correlation in TAAD.