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Central Surgical Association

49th Annual Meeting

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Contemporary Medical Management of Acute Type A Aortic Dissection: Better Outcomes?
Rana-Armaghan Ahmad, Xiaoting Wu, *Karen Kim, *Shinichi Fukuhara, *Himanshu Patel, *George M. Deeb, Gorav Ailawadi, *Bo Yang
cardiac surgery , University of Michigan, Ann Arbor, Michigan, United States


Objective: To evaluate outcomes of medical management of acute type aortic dissection (ATAAD) in the contemporary era.

Methods: From 1996-2021, 920 ATAAD patients were admitted to our institution, including those treated with open aortic repair (surgical, n=797) or without (medical, n=123). The patients managed without open aortic repair were due to severe comorbidities, organ failure from malperfusion syndrome, and patients’ wishes. Data were obtained through a global EHR ICD-9/10 code and chart review, the STS warehouse, and the national death index.

Results: The medical group was older, had higher rates of various comorbidities, and a higher rate of malperfusion syndrome than the surgically managed cohort (all p<0.05). The combined in-hospital and 30-day mortality (since onset of aortic dissection) rate was higher for the medical group (70% vs. 7.9%, p<0.001). (Table 1) IMH (intramural hematoma) (vs. patent false lumen in the ascending aorta) was protective for in-hospital+30-day mortality in medical group (odds ratio=0.37, p=0.03).

In the medical group, the demographics and preexisting comorbidities were similar between first and second decade (1996-2010 vs. 2011-2021). However, patients in the 2011-2021 group had a lower combined in-hospital and 30-day mortality rate (58% vs. 84%, p=0.001) and death from aortic rupture (12% vs. 26%, p=0.04). (Table 2) Compared to patients with patent false lumen in the ascending aorta, patients with ascending IMH had more spinal malperfusion (16% vs. 4.1%, p=0.05), less lower extremity malperfusion (16% vs. 41%, p=0.02). The in-hospital+30-day mortality was lower in patients with IMH (52% vs. 75%, p=0.03). (Table 3) Compared to those with malperfusion syndrome, patients with no malperfusion syndrome were older (75 vs. 63, p<0.001) and less likely to be male (47% vs. 71%, p=0.01). The patients with no malperfusion syndrome had a higher rate of various preexisting comorbidities. The combined in-hospital and 30-day mortality rate was not different between the no malperfusion syndrome vs. malperfusion syndrome groups (64% vs. 72%, p=0.35), nor was death from aortic rupture (14% vs. 21%, p=0.38). (Table 4)

The 5-year survival was lower in the medical group compared to the surgical group (20% vs. 79%, p<0.001). (Figure 1) Within the medical group, patients treated in the first decade had a lower 3-year survival (14% vs. 22%, p=0.03), however, the 3-year survival rate in patients without malperfusion syndrome was similar to that in patients with malperfusion syndrome (29% vs. 16%, p=0.22).

Conclusions: The outcomes improved in last decade for ATAAD patients who were not surgical candidate, but it was still poor as patients frequently died from comorbidities and organ failure from malperfusion syndrome rather than aortic rupture. Surgery should be the treatment of choice for ATAAD patients if patients were candidate.

Data presented as median (25%, 75%) for continuous data and n (%) for categorical data. Abbreviations: AI=aortic insufficiency; BMI=body mass index; CAD=coronary artery disease; COPD=chronic obstructive pulmonary disease; CVA = cerebrovascular accident; MI=myocardial infarction, PVD = peripheral vascular disease; CABG=coronary artery bypass graft. LOS=length of stay. P-value indicates the difference in type A dissection patients between medical management vs. surgical management.
*Combined in-hospital mortality and 30-day mortality includes patients deceased in the hospital or patients deceased 30 days after onset of dissection

Data presented as median (25%, 75%) for continuous data and n (%) for categorical data.
Abbreviations: AI=aortic insufficiency; BMI=body mass index; CAD=coronary artery disease; COPD=chronic obstructive pulmonary disease; CVA = cerebrovascular accident; MI=myocardial infarction, PVD = peripheral vascular disease; CABG=coronary artery bypass graft. LOS=length of stay. P-value indicates the difference between nonoperative cases from 1996-2010 vs. 2011-2021.
*Combined in-hospital mortality and 30-day mortality includes patients deceased in the hospital or patients deceased 30 days after onset of dissection

Data presented as median (25%, 75%) for continuous data and n (%) for categorical data. Abbreviations: AI=aortic insufficiency; BMI=body mass index; CAD=coronary artery disease; COPD=chronic obstructive pulmonary disease; CVA = cerebrovascular accident; MI=myocardial infarction, PVD = peripheral vascular disease; CABG=coronary artery bypass graft. LOS=length of stay. P-value indicates the difference between patients with acute type A intramural hematoma vs. those with patent false lumen in the ascending aorta.
*Combined in-hospital mortality and 30-day mortality includes patients deceased in the hospital or patients deceased 30 days after onset of dissection

Data presented as median (25%, 75%) for continuous data and n (%) for categorical data.
Abbreviations: AI=aortic insufficiency; BMI=body mass index; CAD=coronary artery disease; COPD=chronic obstructive pulmonary disease; CVA = cerebrovascular accident; MI=myocardial infarction, PVD = peripheral vascular disease; CABG=coronary artery bypass graft. LOS=length of stay. P-value indicates the difference between nonoperative cases in patients with no malperfusion syndrome vs. patients with malperfusion syndrome.
*Combined in-hospital mortality and 30-day mortality includes patients deceased in the hospital at time of discharge or patients deceased 30 days after onset of dissection

Figure 1: Kaplan-Meier Survival analysis: Upper panel: patients treated with open aortic repair (surgical group) vs. without open aortic repair (medical group), Middle panel: patients treated in the first decade (1996-2010) vs. second decade (2011-2021), Lower panel: patients with or without malperfusion syndrome


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