Despite the lack of evidence, thoracic endovascular aortic repair (TEVAR) has become the treatment of choice for uncomplicated type B aortic dissection (uTBAD). The purpose of this study was to evaluate the effectiveness of the first TEVAR after uTBAD with medical treatment alone in terms of reducing mortality and morbidity. Adults aged 65 and over with index hospitalizations for acute uTBAD between January 1, 2011, and December 31, 2018, were included in this cohort research using inpatient claims data from the Centers for Medicare & Medicaid Services, with follow-up accessible through December 31, 2019. All-cause mortality, hospitalizations for cardiovascular issues, hospitalizations for aortic issues, hospitalizations for aortic issues a second time, and aortic interventions after the first TEVAR vs. medicinal treatment were included as outcomes using an inverse probability weighting scheme based on the propensity score.
There were 7,105 patients admitted to the hospital with acute uTBAD, 1,140 (16.0%) of whom received their first TEVAR (623 [54.6%] female; median age, 74 years [IQR, 68-80 years]), and 5,965 (84.0%) of whom did not undergo TEVAR (3,344 [56.1%] female; median age, 76 years [IQR, 69-83 years]). There were significant associations with the region (vs South; Midwest: adjusted odds ratio [aOR], 0.66 [95% CI, 0.53-0.81]; P< .001; Northeast: aOR, 0.63 [95% CI, 0.50-0.79]; P< .001), Medicaid dual eligibility (aOR, 0.76; 95% CI, 0.63-0.91; P= .003), hypertension (aOR, 1.26; 95% CI, 1.03-1.54; P= .03), peripheral vascular disease (aOR, 1.24; 95% CI, 1.02-1.49; P= .03), and year of admission (2012, 2013, 2014, and 2015 were associated with greater odds of TEVAR compared with 2011). Mortality rates at 5 years were similar between the 2 strategies (hazard ratio [HR], 0.95; 95% CI, 0.85-1.06), as were rates at 1 year for aorta-related hospitalizations (HR, 1.12; 95% CI, 0.99-1.27), aortic interventions (HR, 1.01; 95% CI, 0.84-1.20), and cardiovascular hospitalizations (HR, 1.05; 95% CI, 0.93-1.20).
Initial TEVAR was related to decreased mortality over 1 year (adjusted HR [aHR], 0.86; 95% CI, 0.75-0.99; P=.03), 2 years (aHR, 0.85; 95% CI, 0.75-0.96; P=.008), and 5 years (aHR, 0.87; 95% CI, 0.80-0.96; P=.004) in a sensitivity analysis that included fatalities during the first 30 days. This research found that hypertension, peripheral vascular disease, location, Medicaid dual eligibility, and year of admission were all linked with administering the first TEVAR within 30 days following uTBAD in 16.0% of patients. Across 5 years, initial TEVAR was not linked with decreased mortality, fewer hospitalizations, or fewer aortic interventions; however, in a sensitivity analysis that included fatalities within the first 30 days, beginning TEVAR was associated with decreased mortality. A prospective study in the United States is needed to evaluate these results and the cost-effectiveness and quality of life.
Source: jamanetwork.com/journals/jamacardiology/article-abstract/2798243
