Trends In Management And Survival Of Medicare Beneficiaries Presenting With Acute Aortic Dissection
Christina L. Marcaccio, MD, MPH1, Priya B. Patel, MD, MPH1, Livia de Guerre, MD2, Kirsten D. Dansey, MD, MPH1, Vinamr Rastogi, MD1, James O'Malley, PhD3, Bruce E. Landon, MD, MBA, MSc1, Marc L. Schermerhorn, MD1.
1Beth Israel Deaconess Medical Center, Boston, MA, USA, 2University Medical Center, Utrecht, Netherlands, 3Geisel School of Medicine at Dartmouth University, Hanover, NH, USA.
OBJECTIVES: Current studies on aortic dissection are limited to clinical registries and referral centers that may not represent national trends. Using nationally representative data on Medicare beneficiaries, we describe initial management of patients with acute aortic dissection and associated survival over time.
METHODS: We identified all fee-for-service Medicare beneficiaries age ≥67 years admitted with acute aortic dissection from 2010-2016. Patients were grouped into cohorts by dissection anatomy and initial management based on diagnosis and procedure codes. We examined trends in management of aortic dissection over time and used Kaplan Meier analysis to estimate 30-day, 1-year, and 5-year survival by cohort.
RESULTS: We identified 34,129 patients with acute aortic dissection (ranging from 4709 to 5143 patients/year): 73% underwent medical management for type A or type B dissection, 18% underwent type A repair, 7.2% underwent endovascular intervention for type B dissection (5.2% TEVAR/2.0% non-TEVAR (e.g., balloon fenestration)), and 2.1% underwent open intervention for type B dissection (1.4% aortic/0.7% non-aortic (e.g., femoral-femoral bypass)). Over time, there was a decrease in medical management (75% in 2010 versus 70% in 2016, p<.001). Concurrently, there was an increase in type A repair (16% versus 20%, p<.001) and endovascular intervention for type B dissection (5.7% versus 8.2%, p<.001) and a concomitant decrease in open intervention for type B dissection (2.9% versus 1.5%, p<.001). Thirty-day and 1-year survival were higher in patients who underwent endovascular intervention for type B dissection and lower in those who underwent open intervention for type B dissection (Figure). After 2 years, survival was higher in patients who underwent type A repair and lower in those who underwent medical management. At 5 years, survival was ≤50% across all cohorts.
CONCLUSIONS: In this large nationally representative study, over 70% of Medicare patients admitted with acute type A or type B aortic dissection were managed medically, but this rate decreased over time as type A repair and endovascular intervention for type B dissection increased. Five-year survival was poor overall, thus highlighting the severity of aortic dissection pathology and the importance of close follow-up and risk factor modification in this population. 
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