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Re-evaluation Of A Standardized Protocol For Treatment Of Acute Type B Aortic Dissections: A Single Center Review And Standard Of Care Update
Leah M. Gober, MD, Ethan Richmond, BS, Sophia Liu, BS, Jack Bontekoe, MD, Carly Sobol, MD, Kate Telma, MD, Girma Tefera, MD, Paul Dimusto, MD, Courtney Morgan, MD.
University of Wisconsin, Madison, WI, USA.
Objective: While recent literature questions whether early surgical intervention may reduce future complications, current treatment for acute type B aortic dissection (TBAD) is largely medical management. Acute aortic protocols consisting of aggressive anti-hypertensive and anti-impulse regimens with ICU-level monitoring have been developed to help standardize care during initial TBAD presentation. This study aims to quantify the impact of our institutional acute aortic protocol on acute TBAD patient outcomes and provided an updated contribution to the current literature supporting conservative acute TBAD treatment.
Methods: A retrospective chart review was performed on all patients who presented with acute TBAD over a 15-year period, with the intention to compare two groups: (1) pre-protocol and (2) post-protocol implementation. Acute TBAD was strictly defined as a new dissection on imaging, <2 weeks of symptoms, with an emphasis to only include patients with primary, isolated pathology. Patients with acute-on-chronic or chronic dissections and intramural hematomas or ulcers were excluded. Primary outcomes included in-hospital morbidity, in-hospital mortality, and need for surgery. Secondary outcomes included ICU LOS, discharge antihypertensive medications and readmission rates. Categorical variables were analyzed using chi-square; Kaplan-Meier and Log-Rank tests were used to assess survival.
Results: A total of 177 patients admitted with acute TBAD were identified: 97 pre-protocol implementation and 80 post-implementation. Pre-protocol patients had a higher rate (42 vs 27%, p < 0.01) and hazard (p < 0.01, Figure 1) of undergoing surgery, however no differences were observed across in-hospital mortality, morbidity, or readmission rates (p > 0.05 for all) between the two groups. Furthermore, post-protocol patients had shorter average ICU stays (3.3±4.7 vs 5.4±4.1 days, p <0.05) and were discharged on fewer outpatient antihypertensives (3.2±1.6 vs 3.8±1.6, p < 0.05).
Conclusions: Implementation of a standardized protocol resulted in reduced ICU LOS, lower incidence of surgery and fewer antihypertensives required on discharge without a difference in in-hospital mortality, morbidity or 30- and 90-day readmission rates. This data, from a highly selective patient population, suggests that standardizing medical management of acute aortic syndromes continues to provide patients with benefit of freedom from surgery without compromising patient outcomes.
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