The Collaborative Acute Aortic Syndrome Project (CAASP): understanding diagnostic pathways and their impact on survival

Singh, Aminder, Zhong, Jim, Safdar, Nawaz, Vigneswaran, Ganesh and Nandhra, Sandip , CAASP Collaborators (2024) The Collaborative Acute Aortic Syndrome Project (CAASP): understanding diagnostic pathways and their impact on survival. European Journal of Vascular and Endovascular Surgery, 67 (3), e49-e50. (doi:10.1016/j.ejvs.2024.01.044).

Abstract

Objective: the primary aim of this study was to identify the factors related to time from symptom onset to hospital presentation and subsequent outcomes in patients presenting with acute aortic syndrome (AAS).

Methods: this national multicentre, retrospective study is a patient led initiative coordinated by the UK National Interventional Radiology Trainee Research (UNITE) collaborative and Vascular and Endovascular Research Network (VERN) partnered with The Aortic Dissection Charitable Trust (TADCT). Consecutive patients diagnosed on imaging with AAS between 1 January 2018 and 1 June 2021 were included and followed up for six months. A multi-way analysis of variance was used to determine variables (demographic, clinical symptoms/signs, comorbidities, vital signs) associated with longer time to hospital presentation (TTHP). A logistic regression model was used to determine variables associated with 30 day mortality.

Results: a total of 590 patients from 14 UK hospitals were included. Median age (IQR) was 71 (58, 80) years, and 370 (62.7%) patients were male and 473 (80.2%) were Caucasian. The most frequent aortic pathology was type A dissection 244/588 (41.5%), followed by type B dissection 206/588 (35.0%), and other AAS types 138/588 (23.5%). Of the patients, 221/536 (41.2%) had complicated AAS. The most common presenting symptoms were pain in the chest (73.9%, 413/559), back (66.2%, 343/518), or abdomen (37.2%, 185/497), with sudden onset pain present in 80.5% (433/538); 19.6% (100/510) presented with collapse. The most common presenting signs were a blood pressure differential (31.1%, 68/219), hypotension (19.7%, 106/539), focal neurology (14.7%, 67/457), coma (11.9%, 67/564), and new murmur (9.3%, 42/450). Mode of presentation included by emergency ambulance (79.5%), self-presentation to hospital (13.4%), and through primary care referral (1.9%). Median distance (range) from admitting hospital was 6.5 (0.5 – 199) miles. Median index of deprivation score was 6 (1 – 10). The median TTHP was 3.1 (1.8 – 8.6) hours. The median time from admission to imaging was 3.2 (1.2 – 6.7) hours and median time from imaging to treatment was 2 (1 – 4.5) hours. Mode of presentation (primary care referral > ambulance or self-presentation), absence of sudden onset chest pain symptoms, history of bicuspid aortic valve and previous cardiac surgery all significantly increased TTHP (p < .05). The 30 day mortality rates (Table 1) were highest for by non-A non-B (38.5%) followed by type A dissection (33.8%), penetrating aortic ulcer (26.3%), type B dissection (17.3%), and intramural haematoma (6.2%). Increase in age, type of aortic pathology, time from symptom onset to hospital presentation, presence of complicated AAS, and increased length of ICU stay were significantly associated with higher 30 day mortality (p < .05).

Conclusion: the Collaborative Acute Aortic Syndrome Project (CAASP) has identified factors that influence TTHP (type of referral, sudden onset symptoms, cardiovascular comorbidities) and 30 day mortality rates (age, type of AAS, TTHP, presence of AAS complications, ICU length of stay) in the UK. This can be used to optimise diagnostic pathways with the aim of improving patient outcomes.

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Contributors

Author: Ganesh Vigneswaran

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