Imaging Surveillance Adherence for Uncomplicated Type B Aortic Dissection at a Regional Referral Center

Background: Medical management with anti-impulse therapy and imaging surveillance remains the standard of care for the majority of uncomplicated type B aortic dissections (uTBAD). Failure to adhere to surveillance recommendations may increase the likelihood of aortic degeneration and complications and affect long-term mortality. We sought to analyze adherence to imaging surveillance and identify risk factors for nonadherence in our practice.

Methods: In this single-center, retrospective cohort study, demographics, follow-up, and outcomes of patients with acute or subacute uTBAD from August, 20211 to November, 2021 were analyzed. Outcomes were compared between patients with and without routine imaging surveillance. Imaging surveillance was defined as aorta-directed imaging with associated in-person or telephone encounter ≥3 months from index hospitalization. Univariate analysis was used to compare patients with and without imaging surveillance. Multivariate logistic regression was performed to identify factors related to increased odds of adherence to imaging surveillance.

Results: A total of 152 medically managed acute or subacute uTBAD patients were identified. Seventy (46.0%) patients underwent imaging surveillance for a median of 16 (interquartile range [IQR] 3.5-29) months. There were no differences in age, sex, race, insurance status, or smoking status between patients with and without surveillance. The median patient home address was 96.1 miles from our center, with no difference between the surveillance (85.7 [IQR 63.5-149.9]) versus no surveillance (106.7 [IQR 70.6-157.6]) groups (P = 0.32). Prior cardiovascular surgery (22.0% vs. 5.7%, P < 0.01) was more common in those without surveillance. Most patients (94.7%) presented as hospital transfers, with no difference between surveillance and non-surveillance groups (P = 0.15). Patients with surveillance were more likely to be discharged home (92.9% vs. 69.5%, P < 0.01). Postdischarge thoracic endovascular aortic repair (TEVAR) occurred in 13.8% of patients and was more common in the surveillance group (25.7% vs. 3.7%, P < 0.01). In TEVAR patients, there was no difference between the rate of urgent or emergent intervention between (P = 1.00) and no difference in the median time to TEVAR (P = 0.15) for surveillance and nonsurveillance groups. Discharge home (OR 5.78, [95% confidence interval [CI] 1.86-17.95, P < 0.01]) was associated with greater odds of imaging surveillance adherence. Previous cardiovascular surgery (OR 0.21, [95% CI 0.06-0.73, P = 0.02]), history of drug use (OR 0.31, [95% CI 0.10-0.97, P = 0.05]), and age (0.96 per unit increase, [95% CI 0.93-0.99, P = 0.02]) were associated with lower odds of imaging surveillance. There was no difference in 5-year survival between groups (log-rank P = 0.26).

Conclusions: Adherence to uTBAD imaging surveillance was low and did not vary by patient demographics or distance from hospital. Patients with imaging surveillance were more likely to undergo TEVAR, although there were no differences in 5-year all-cause survival between groups. Home discharge was associated with the greatest odds of imaging surveillance adherence. This study highlights the difficulty in regional referral center care coordination for treatment of medically managed uTBAD and identifies several factors that may help identify at-risk patients.