Bariatric Surgery Tied to Lower Aortic Dissection Risk

Laird Harrison

October 15, 2020

People who have undergone bariatric surgery appear less likely to suffer an aortic dissection than other adults with obesity, researchers say.

The finding is the latest in a series of benefits researchers have linked to the surgery, not all of which appear to directly result from weight loss.

"It has an incredible impact on hyperlipidemia and hypertension," said Luis Felipe Okida, MD, from Cleveland Clinic Florida in Weston. "Those are the main risk factors for aortic dissection."

He presented the finding at the virtual American Congress of Surgeons (ACS) Clinical Congress 2020. The study was also published online in the Journal of the American College of Surgeons.

Although uncommon, acute aortic dissection proves fatal to half the people it strikes if patients do not receive treatment within 72 hours, Okida told Medscape Medical News.

To learn whether there is an association between bariatric surgery and risk for aortic dissection, Okida and his colleagues analyzed data from the National Inpatient Sample (NIS) database from 2010 to 2015. The NIS comprises about 20% of hospital inpatient admissions in the United States.

Among the patients in the sample, 296,041 adults had undergone bariatric surgery, and 2,004,804 adults had obesity (body mass index ≥35 kg/m2) but had never undergone bariatric surgery. This latter group represented the control group.

Among the control group, 1411 patients (.070%) experienced aortic dissection; among the bariatric surgery group, 94 patients (.032%) experienced aortic dissection. This was a statistically significant difference (P < .0001).

The groups differed significantly in many ways. The mean age of the patients in the control group was 54.4 years, which was a mean of 2.5 years older than the bariatric surgery group. Additionally, the control group included a higher percentage of women and a lower percentage of White persons.

Those in the control group were also more likely to have a history of tobacco use, hypertension (64.2% vs 48.9% in the surgery group), hyperlipidemia (32.7% vs 18.3%), diabetes, aortic aneurysm (20.6% vs 12.0%), and bicuspid aortic valves but were less likely to have Marfan/Ehlers-Danlos syndrome.

A multivariate analysis showed that gender, age, history of tobacco use, hypertension, hyperlipidemia, and Marfan/Ehlers-Danlos syndrome were associated with an increased risk for aortic dissection. Diabetes was associated with a lower risk. All of these findings had previously been reported in the literature, Okida said, but the reasons for the negative association with diabetes is not well understood.

The association between the surgery and aortic dissection applied to younger patients as well as older ones.

Table. Adjusted Risk of Aortic Dissection: Control vs Surgery

Patients' age Odds ratio 95% confidence interval value
All ages 1.81 1.44 – 2.29 <.001
Aged 18 – 39 years 2.95 1.09 – 7.99 .0345
Aged 40 – 90 years 1.75 1.38 – 2.22 <.0001


"In elderly patients, the main risk factor for aortic dissection is hypertension, and in younger patients, below 40 years old, the main risk factors are diseases of the collagen and diseases of the aorta," said Okida during his presentation. "But these younger patients still have a high prevalence of hypertension, and that's why bariatric surgery is beneficial."

Although the finding regarding risk for aortic dissection supports the value of bariatric surgery, it does not in itself provide justification for undergoing the procedure. "It's not even one of the comorbidities that insurance companies would recognize as key in approving this procedure," said senior author Emanuele Lo Menzo, MD, PhD, also from the Cleveland Clinic Florida.

"I don't think a physician would ever recommend this procedure specifically to avoid aortic dissection," he told Medscape Medical News. "It's sort of an extended benefit."

The study raises interesting questions about the effects of the surgery, said Shanu Kothari, MD, president elect of the American Society for Metabolic and Bariatric Surgery.

"We've known for a long time that patients with chronic obesity who undergo weight loss surgery live longer than those who don't," he told Medscape Medical News. "They have less cardiovascular disease and cancer. Is this one more reason that they live longer?"

Bariatric surgery produces benefits for people with diabetes the day after the surgery, long before patients lose weight as a result of the procedure, Kothari said.

The effects on metabolism are complex, he added. Besides caloric restriction, they include changes in bile salt absorption and the gut microbiome, which in turn can affect hormones and inflammation.

A key question is how long after the surgery the risk for aortic dissection starts to decline, said Kothari.

The study could not answer such questions, and Okida could not find any previous studies that explored the association. He also couldn't find any study that examined whether weight loss by other means might also reduce the risk for aortic dissection.

Okida, Lo Menzo, and Kothari have disclosed no relevant financial relationships.

ACS Clinical Congress 2020.

J Am Coll Surg. Published online October 1, 2020. Abstract

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