Adherence to Long-Term Follow-Up in Patients Presenting with Acute Type A and B Aortic Dissection
Livia E.V.M. de Guerre1, Barabara Dalebout1, Rens R.B. Varkevisser1, Nicholas J. Swerdlow1, Chun Li1, Patric Liang1, Thomas F.X. O'Donnell1, Joost A. van Herwaarden2, Marc L. Schermerhorn1.
1BIDMC, Boston, MA, USA, 2UMCU, Utrecht, Netherlands.
Objective: Patients surviving the acute phase of an aortic dissection require lifetime follow-up in accordance to multispecialty guidelines after 1, 3, 6, 12 months, and yearly thereafter. However, the adherence to recommended follow-up and its potential impact are unclear. Therefore, we assessed adherence to follow-up, the type of imaging used, and the association between follow-up adherence and survival in patients with acute aortic type A and B dissection.
Methods: We performed an institutional retrospective cohort study of patients with type A or type B aortic dissection, intramural hematoma (IMH) or penetrating aortic ulcer (PAU) from 2002 to 2014 using ICD-9 codes. Patients who died within 3 months from diagnosis were excluded. For patients not followed at our institution, we contacted the patient or primary care physician and inquired about appropriate follow-up. The primary outcome was adherence to follow-up, categorized as ‘adequate’ if imaging studies occurred with a maximum gap of 18 months, ‘inadequate’ if at least one gap of more than 18 months existed between imaging studies, ‘lost to follow-up’ if after initial follow-up, no subsequent imaging occurred or as ‘no follow-up’ if no imaging was performed after discharge. Secondary outcomes included the imaging type used and long-term survival.
Results: We identified 217 patients with type A dissections (46%), type B dissections (45%), PAU (6%), and IMH (3%). Overall, 17% had no follow-up, 28% were lost to follow-up, 30% received inadequate follow-up, and 25% received adequate follow-up. Median follow-up was 3 years and 20 days (IQR 218-2194 days). Patients without follow-up were older (median age 71 [IQR 57-80] vs. 62 [IQR 52-70], P<.001). Patients who presented with Type A dissections had higher follow-up adherence rates (47% vs. 65%, P=.009). Follow-up imaging was mostly performed with CTA (88%) and for patients without follow-up, survival at 5 years was 77% compared to 89% in patients with follow-up (log-rank .008) (figure).
Conclusion: Follow-up rates after aortic dissection, IMH and PAU were very low, and lack of adherence to follow-up recommendations was associated with lower long-term survival. These results highlight an important area of quality improvement in follow-up management for patients with aortic dissections. 
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