Readmission following early thoracic endovascular aortic repair compared to optimal medical treatment for uncomplicated acute type B aortic dissection

Abstract

Background

There is a lack of consensus on the benefit of early thoracic endovascular aortic repair (TEVAR) over medical management for uncomplicated acute type B aortic dissection (aTBAD). The aim of this study is to compare readmissions of TEVAR versus medical management as the initial treatment strategy for uncomplicated aTBAD using the Nationwide Readmissions Database (NRD).

Methods

The NRD was created under the Healthcare Cost and Utilization Project, comprising over half of the U.S. inpatient population. Patients admitted for uncomplicated aTBAD were queried from the NRD from 2016 to 2018. Risk of index admission mortality, spinal cord ischemia, stroke, and overall major complication; 90-day readmission and 90-day treatment failure, between TEVAR and medical management alone.

Results

A total of 12,645 patients with an uncomplicated aTBAD were identified (TEVAR 12% and medical management 88%). Overall major complications during index admission were higher in the medical management group (27% vs 40%, p < .0001). On multivariate analysis TEVAR was associated with lower mortality (OR: 0.47, p < .0001), but a significantly higher rate of spinal cord ischemia (OR: 2.49, p < .0001), with no difference in stroke (OR: 0.93, p = .73). 90-day readmission rates were high but were not significantly different between treatment types (22% vs 25%, OR: 0.88, p = .14). Similarly, TEVAR was not associated with a lower rate of 90-day treatment failure (OR: 0.61, p = .22). Four TEVAR (0.3%) and 40 medical management (0.5%) patients were readmitted for treatment failure due to retrograde type A dissection.

Conclusions

TEVAR for uncomplicated aTBAD was not associated with a lower 90-day readmission rate. Similarly, TEVAR was not associated with a lower rate of 90-day treatment failure. These findings provide further evidence to the equipoise of treatment options and support the need for the randomized trials currently ongoing in the U.S. and Europe investigating outcomes of TEVAR versus medical management for the treatment of uncomplicated aTBAD.

Keywords

Type B aortic dissection readmission thoracic endovascular aortic repair nationwide readmission database

Introduction

Historically, acute type B aortic dissections (aTBAD) have been empirically treated with optimal medical management (OMT) via impulse control to lower the heart rate and blood pressure. This widely accepted standard of care came from early findings of the International Registry of Acute Aortic Dissection (IRAD) in 2000 showing in-hospital mortality rates for medically treated aTBAD was 10.7% while those treated surgically was 31.4%.¹ However, later IRAD results showed that medically managed patients had poor long-term outcomes, highlighting the need for reevaluation of how to best treat aTBAD.²

After early studies showing impressive results using thoracic endovascular aortic repair (TEVAR) to treat complicated aTBAD, TEVAR has been increasingly used to treat uncomplicated aTBAD (uaTBAD).³ Several studies have shown that TEVAR and OMT have comparable in-hospital mortality, while having a high likelihood of inducing thrombosis of the false lumen.^4–7 Although the 2014 European Society of Cardiology (ESC) guidelines on aortic diseases disclosed evidence supporting the early use of TEVAR for uaTBAD, it was insufficient for a recommendation, emphasizing the lack of consensus on management.⁸ Early TEVAR has been shown to have decreased rates of aneurysmal degeneration in the stented aorta, need for reintervention, and is more efficacious than TEVAR performed in the chronic phase of TBAD.^4–7,9–11 Outcomes of TEVAR also vary based on the presence of a complicated TBAD, high-risk features, and dissections extending beyond the aorta.^12–16 Despite these potential benefits, studies showed continued degeneration of the visceral aorta requiring further interventions.^17–21 Additionally, early TEVAR exposes patients to procedural risks such as stroke, spinal cord ischemia (SCI), retrograde type A aortic dissection (TAAD), and complications associated with lumbar drain placement.^22–27 Indeed, worse outcomes have been observed in early TEVAR than in sub-acute or chronic phases.^28,29 TEVAR’s impact on hospital length of stay and costs also remains an area of debate.^30,31

The primary aim of this study is to evaluate 90-day readmissions and treatment failure of TEVAR compared to OMT as the initial treatment strategy for uaTBAD using the Nationwide Readmissions Database (NRD). The NRD is the first all-payer national database allowing readmission data analysis throughout a calendar year and has successfully been used to study readmission factors for other vascular pathologies.^32–36 The hypothesis was that early TEVAR would be associated with lower readmission rates than OMT for uaTBAD.

Methods

Data source

The NRD comprises 57.8% of the U.S. population, encompassing 27 states. This database uses de-identified patient linkage numbers to reliably track patients between hospitals within state lines within a calendar year. Specifically, we queried patients from 2016 to 2018.

Study population

Inclusion criteria were adults diagnosed with aTBAD who underwent either TEVAR or OMT. These criteria were identified using the International Classification of Diseases, Tenth Edition, Clinical Modification (ICD-10CM) codes of diagnoses and procedures (Appendix Table 1). Index admission exclusion criteria included chronic, iatrogenic, or traumatic etiologies, open repair, complicated TBAD, and TAAD, and those who died during index hospitalization were excluded from readmissions analysis (Appendix Table 2). Complicated TBAD was defined as aortic rupture or malperfusion signs as per the current Society for Vascular Surgery/Society of Thoracic Surgeons reporting standards for TBAD.³⁷ Procedural codes of ascending/arch repair, cardioplegia, valve repair, and operations on heart vessels were excluded to differentiate TAAD from TBAD.

Patient/hospital characteristics

Patient and index hospital characteristics were extracted from the NRD for univariate and multivariate analyses. Hospital factors, patient factors, existing comorbidities, and clinical characteristics were assessed.

Statistical analysis

Descriptive analyses were performed for patient demographics, clinical characteristics, and hospital characteristics across treatment groups. Multivariable logistic regression was used for all outcomes, which includes index hospitalization mortality, stroke, SCI, 90-day all cause readmission, and 90-day treatment failure. For readmission outcomes, only Jan–Sep data were used so all patients had at least 3-month follow-up within the calendar year. The primary exposure variable was treatment group (TEVAR vs OMT). All variables tested in descriptive analyses were considered as potential confounders and were included initially. Variables acting as confounders or p < .05 remained in the final model for each outcome. Confounding variables were defined as changing the estimated OR >10%. Generalized estimation equations were applied to account for hospital clustering. Logistic model assumptions were checked using Hosmer–Lemeshow goodness-of-fit test. A p-value <.05 was considered statistically significant. Analysis was performed using SAS, version 9.4 (SAS Institute, Cary, North Carolina, USA).

The primary outcome was 90-day all-cause readmission. Secondary outcomes were 90-day treatment failure (defined as undergoing TEVAR, open aortic repair, or ascending/arch repair on readmission), inpatient mortality, stroke, and SCI.

Results

Patient/hospital baseline characteristics

The 2016-2018 NRD had 12,645 patients who satisfied the inclusion criteria for uaTBAD. Of these, 1543 were treated with TEVAR (12.2%) and 11,102 received OMT (87.8%). There were more males (53.1% n = 6717 vs 46.9% n = 5928), especially in the TEVAR cohort (59.2%, n = 913 vs 40.8%, n = 630) (Table 1). Most patients were ≥60 years (60–74: 34.1%, n = 4307; ≥75: 37.1%, n = 4693), while those treated with TEVAR tended to be younger (45–59: 27.4%, n = 423; 60–74: 40.6%, n = 627; ≥75: 23.7%, n = 365) (Table 1). Patients were primarily admitted to large (70.1%, n = 8861) and teaching (82.4%, n = 10,421) hospitals, especially those treated with TEVAR. (80%, n = 1235; 89.6%, n = 1382) (Table 1).

Table 1.

Patient demographics of index admission cohort separated by treatment type.

	Total cohort		TEVAR		Medical management		p-Value
	N	%	N	%	N	%	p-Value
Total			1543	12.2	11102	87.8
Age							<0.0001
18–44	955	7.6	128	8.3	827	7.4
45–59	2690	21.3	423	27.4	2267	20.4
60–74	4307	34.1	627	40.6	3680	33.1
≥75	4693	37.1	365	23.7	4328	39
Gender							<0.0001
Male	6717	53.1	913	59.2	5804	52.3
Female	5928	46.9	630	40.8	5298	47.7
Insurance							<0.0001
Missing	24	0.2	6	0.4	18	0.2
Medicare	7915	62.6	827	53.6	7088	63.8
Medicaid	1394	11	188	12.2	1206	10.9
Private insurance	2489	19.7	401	26	2088	18.8
Self-pay	444	3.5	66	4.3	378	3.4
No charge	57	0.5	8	0.5	49	0.4
Other	322	2.5	47	3	275	2.5
LOS							<0.0001
0–2	3474	27.5	188	12.2	3286	29.6
3–4	2946	23.3	301	19.5	2645	23.8
5–8	3532	27.9	508	32.9	3024	27.2
≥9	2693	21.3	546	35.4	2147	19.3
Disposition							<0.0001
Missing	12	0.1	1	0.1	11	0.1
Routine	6530	51.6	946	61.3	5584	50.3
Other	6103	48.3	596	38.6	5507	49.6
Median household income percentile for patient’s ZIP code, based on current year							0.06
Missing	170	1.3	26	1.7	144	1.3
0–25	3562	28.2	457	29.6	3105	28
26–50	3191	25.2	413	26.8	2778	25
51–75	3040	24	340	22	2700	24.3
76–100	2682	21.2	307	19.9	2375	21.4
Teaching hospital							<0.0001
Non-teaching	2224	17.6	161	10.4	2063	18.6
Teaching	10421	82.4	1382	89.6	9039	81.4
Metropolitan							0.95
Other	4573	36.2	557	36.1	4016	36.2
Major metropolitan	8072	63.8	986	63.9	7086	63.8
Bed size of hospital							<0.0001
Small	987	7.8	45	2.9	942	8.5
Medium	2797	22.1	263	17	2534	22.8
Large	8861	70.1	1235	80	7626	68.7
Control/ownership of hospital							0.06
Government, nonfederal	1510	11.9	211	13.7	1299	11.7
Private, not-profit	9850	77.9	1187	76.9	8663	78
Private, invest-own	1285	10.2	145	9.4	1140	10.3
Congestive heart failure							<0.0001
No	9596	75.9	1339	86.8	8257	74.4
Yes	3049	24.1	204	13.2	2845	25.6
Cardiac disease							0.44
No	12295	97.2	1505	97.5	10790	97.2
Yes	350	2.8	38	2.5	312	2.8
Valvular disease							<0.0001
No	11458	90.6	1454	94.2	10004	90.1
Yes	1187	9.4	89	5.8	1098	9.9
Peripheral vascular disease
Yes	12645	100	1543	100	11102	100
Neurological disorders/paralysis							0.37
No	8032	63.5	996	64.5	7036	63.4
Yes	4613	36.5	547	35.5	4066	36.6
Cerebrovascular disease							<0.0001
No	11157	88.2	1432	92.8	9725	87.6
Yes	1488	11.8	111	7.2	1377	12.4
COPD							0.08
No	10244	81	1275	82.6	8969	80.8
Yes	2401	19	268	17.4	2133	19.2
DM							<0.0001
No	10337	81.7	1326	85.9	9011	81.2
Yes	2308	18.3	217	14.1	2091	18.8
Renal failure							<0.0001
No	11903	94.1	1487	96.4	10416	93.8
Yes	742	5.9	56	3.6	686	6.2
Renal disease							0.002
No	10254	81.1	1296	84	8958	80.7
Yes	2391	18.9	247	16	2144	19.3
Obesity							0.0002
No	10884	86.1	1281	83	9603	86.5
Yes	1761	13.9	262	17	1499	13.5
Myocardial infarction							<0.0001
No	11199	88.6	1425	92.4	9774	88
Yes	1446	11.4	118	7.6	1328	12
HTN							<0.0001
No	5323	42.1	481	31.2	4842	43.6
Yes	7322	57.9	1062	68.8	6260	56.4
Elixhauser comorbidity score							<0.0001
1	301	2.4	36	2.3	265	2.4
2	1453	11.5	238	15.4	1215	10.9
≥3	10891	86.1	1269	82.2	9622	86.7

Major complications at index admission

Major complications during index admission were assessed for both treatment groups. There was a lower incidence of ≥1 major complication in the TEVAR cohort than OMT (26.6% vs 40.2%, p < .0001) as were most individual major complications (Table 2). However, TEVAR had higher incidence of SCI than OMT (2.8% vs 1.7%, p = .003) (Table 2).

Table 2.

Index admission major complications for treatment groups. Frequency represented with n-value and percentages; p-values included.

Index admission complications	Total cohort		TEVAR		Medical management		p-Value
Index admission complications	N	%	N	%	N	%	p-Value
Any major complication							<0.0001
No	7775	61.5	1133	73.4	6642	59.8
Yes	4870	38.5	410	26.6	4460	40.2
Pneumonia							<0.0001
No	11428	90.4	1468	95.1	9960	89.7
Yes	1217	9.6	75	4.9	1142	10.3
PE							0.31
No	12142	96	1489	96.5	10653	96
Yes	503	4	54	3.5	449	4
Renal failure							0.0006
No	10186	80.6	1293	83.8	8893	80.1
Yes	2459	19.4	250	16.2	2209	19.9
CVA							<0.0001
No	12085	95.6	1507	97.7	10578	95.3
Yes	560	4.4	36	2.3	524	4.7
MI							<0.0001
No	12092	95.6	1526	98.9	10566	95.2
Yes	553	4.4	17	1.1	536	4.8
Cardiac arrest							<0.0001
No	12271	97	1524	98.8	10747	96.8
Yes	374	3	19	1.2	355	3.2
ARDS							0.43
No	12628	99.9	1542	99.9	11086	99.9
Yes	17	0.1	1	0.1	16	0.1
Sepsis							<0.0001
No	12108	95.8	1518	98.4	10590	95.4
Yes	537	4.2	25	1.6	512	4.6
Septic shock							0.009
No	12517	99	1537	99.6	10980	98.9
Yes	128	1	6	0.4	122	1.1
SCI							0.003
No	12413	98.2	1500	97.2	10913	98.3
Yes	232	1.8	43	2.8	189	1.7

Associations of TEVAR with index admission outcomes

Using multivariable logistic regression analysis, mortality risk, stroke, and SCI were assessed. TEVAR was associated with lower index admission mortality than OMT (OR 0.47, 95% CI: 0.33–0.65, p < .0001) (Table 3). While no associations were found for stroke, TEVAR was associated with higher rates of SCI (OR: 2.49, 95% CI: 1.72–3.61, p < .0001) (Tables 4 and 5).

Table 3.

Index admission mortality. Treatment groups were compared using multivariate logistic regression analysis. Values for odds ratio (OR), confidence interval (CI), and p-value are included. Frequency represented with n-values and percentages. Variables: treatment group, age, gender, income, insurance, APR-DRG disease severity, hospital bed size, hospital area, and major complication.

Variables	OR	95% CI		p-Value	No		Yes
Variables	OR	95% CI		p-Value	N	%	N	%
TEVAR	0.47	0.33	0.65	<.0001	1466	13	43	3.8
Medical	Ref				9853	87	1080	96.2
Age
18–44	Ref				898	7.9	37	3.3
45–59	1.33	0.90	1.97	0.15	2504	22.1	131	11.7
60–74	1.81	1.23	2.67	0.00	3954	34.9	283	25.2
≥75	3.95	2.69	5.80	<.0001	3963	35	672	59.8
Gender
Male	Ref				6132	54.2	482	42.9
Female	1.26	1.11	1.44	0.00	5187	45.8	641	57.1
Median household income percentile for patient’s ZIP code, based on current year
0–25	Ref				3274	28.9	273	24.3
26–50	1.10	0.92	1.33	0.29	2898	25.6	286	25.5
51–75	1.06	0.88	1.27	0.57	2761	24.4	275	24.5
76–100	1.35	1.12	1.62	0.00	2386	21.1	289	25.7
Insurance
Medicare	1.07	0.79	1.46	0.67	6970	61.6	850	75.7
Medicaid	Ref				1310	11.6	62	5.5
Private insurance	1.20	0.87	1.67	0.26	2301	20.3	144	12.8
Self-pay	2.08	1.35	3.20	0.00	403	3.6	34	3
No charge	3.09	1.36	7.04	0.01	51	0.5	5	0.4
Other	1.53	0.94	2.49	0.09	284	2.5	28	2.5
APRDRG disease severity
Minor	Ref				519	4.6	8	0.7
Moderate	1.09	0.50	2.35	0.83	2062	18.2	49	4.4
Major	2.24	1.09	4.62	0.03	6330	55.9	443	39.4
Severe	7.15	3.46	14.77	<.0001	2408	21.3	623	55.5
Bed size of hospital
Small	0.87	0.68	1.11	0.27	865	7.6	107	9.5
Medium	0.77	0.65	0.91	0.00	2532	22.4	225	20
Large	Ref				7922	70	791	70.4
Metropolitan
Other	1.35	1.17	1.55	<.0001	4004	35.4	466	41.5
Major metropolitan	Ref				7315	64.6	657	58.5
Major complication
Yes	1.82	1.59	2.10	<.0001	7229	63.9	414	36.9
No	Ref				4090	36.1	709	63.1

Table 4.

Index admission stroke. Treatment groups were compared using multivariate logistic regression analysis. OR, CI, and p-value are included. Frequency represented with n-values and percentages. Variables: treatment group, age, and APR-DRG disease severity.

Variables	OR	95% CI		p-Value	No		Yes
Variables	OR	95% CI		p-Value	N	%	N	%
TEVAR	0.96	0.65	1.41	0.82	1466	13.2	32	7.6
Medical	Ref				9617	86.8	390	92.4
Age
18–44	Ref				899	8.1	18	4.3
45–59	1.83	1.08	3.10	0.02	2470	22.3	85	20.1
60–74	1.91	1.17	3.11	0.01	3873	34.9	150	35.5
≥75	2.00	1.23	3.26	0.01	3841	34.7	169	40
APRDRG disease severity
Minor	Ref				530	4.8	2	0.5
Moderate	1.12	0.24	5.33	0.88	2095	18.9	9	2.1
Major	7.37	1.75	30.98	0.01	6247	56.4	180	42.7
Severe	26.71	6.35	112.30	<.0001	2211	19.9	231	54.7

Table 5.

Index admission SCI. Treatment groups were compared using multivariate logistic regression analysis. OR, CI, and p-value are included. Frequency represented with n-values and percentages. Variables: treatment group, gender, insurance, and APR-DRG disease severity.

Variables	OR	95% CI		p-Value	No		Yes
Variables	OR	95% CI		p-Value	N	%	N	%
TEVAR	2.49	1.72	3.61	<.0001	1453	12.9	39	19.4
Medical	Ref				9828	87.1	162	80.6
Gender
Male	Ref				6078	53.9	135	67.2
Female	0.53	0.40	0.71	<.0001	5203	46.1	66	32.8
Insurance
Medicare	0.73	0.49	1.08	0.11	6934	61.5	120	59.7
Medicaid	Ref				1300	11.5	31	15.4
Private insurance	0.75	0.47	1.20	0.23	2302	20.4	40	19.9
Self-pay	0.21	0.05	0.84	0.03	407	3.6	2	1
No charge	0.81	0.11	5.93	0.83	51	0.5	1	0.5
Other	0.99	0.44	2.24	0.99	287	2.5	7	3.5
APRDRG disease severity
Minor	Ref				531	4.7	1	0.5
Moderate	6.34	0.84	47.78	0.07	2078	18.4	18	9
Major	14.34	1.97	104.09	0.01	6319	56	96	47.8
Severe	34.77	4.79	252.57	0.00	2353	20.9	86	42.8

Associations of TEVAR with 90-day readmission outcomes

TEVAR was not associated with lower all-cause 90-day readmissions (OR: 0.88, 95% CI: 0.75–1.04, p = .14), nor 90-day treatment failure (OR: 0.61, 95% CI: 0.28–1.33, p = .22) (Tables 6 and 7).

Table 6.

90-day all-cause readmission outcomes. Treatment groups were compared using multivariate logistic regression analysis to assess all-cause readmission and readmission for treatment failure. OR, CI, and p-value are included. Frequency represented with n-values and percentages. Variables: treatment group, age, insurance, APR-DRG disease severity, hospital bed size, teaching hospital, major complication, discharge disposition, and index hospital length of stay.

Variables	OR	95% CI		p-Value	No		Yes
Variables	OR	95% CI		p-Value	N	%	N	%
TEVAR	0.88	0.75	1.04	0.14	901	14	254	12.3
Medical	Ref				5549	86	1816	87.7
Age
18–44	Ref				490	7.6	196	9.5
45–59	0.81	0.66	0.99	0.04	1459	22.6	463	22.4
60–74	0.68	0.56	0.84	0.00	2259	35	716	34.6
≥75	0.55	0.44	0.69	<.0001	2242	34.8	695	33.6
Insurance
Medicare	0.87	0.73	1.04	0.13	3898	60.4	1319	63.7
Medicaid	Ref				686	10.6	307	14.8
Private insurance	0.55	0.46	0.66	<.0001	1425	22.1	329	15.9
Self-pay	0.54	0.40	0.75	0.00	243	3.8	56	2.7
No charge	0.97	0.50	1.88	0.94	26	0.4	11	0.5
Other	0.68	0.48	0.98	0.04	172	2.7	48	2.3
APRDRG disease severity
Minor	Ref				320	5	92	4.4
Moderate	0.68	0.52	0.89	0.00	1282	19.9	283	13.7
Major	0.91	0.71	1.16	0.45	3547	55	1159	56
Severe	0.92	0.70	1.21	0.56	1301	20.2	536	25.9
Bed size of hospital
Small	0.82	0.68	0.99	0.04	514	8	136	6.6
Medium	1.15	1.02	1.31	0.02	1360	21.1	495	23.9
Large	Ref				4576	70.9	1439	69.5
Teaching hospital
Non-teaching	1.20	1.05	1.37	0.01	1094	17	409	19.8
Teaching	Ref				5356	83	1661	80.2
Major complication
Yes	1.17	1.04	1.31	0.01	4233	65.6	1199	57.9
No	Ref				2217	34.4	871	42.1
Discharge disposition
Routine	Ref				3865	59.9	979	47.3
Other	1.54	1.37	1.73	<.0001	2585	40.1	1091	52.7
LOS
0–2	Ref				1598	24.8	392	18.9
3–4	1.22	1.05	1.42	0.01	1624	25.2	477	23
5–8	1.25	1.07	1.45	0.00	1904	29.5	598	28.9
≥9	1.60	1.37	1.88	<.0001	1324	20.5	603	29.1

Table 7.

90-day treatment failure. Treatment groups were compared using multivariate logistic regression analysis to assess all-cause readmission and readmission for treatment failure. OR, CI, and p-value are included. Frequency represented as n-values and percentages. Variables: treatment group, age, and insurance.

Variables	OR	95% CI		p-Value	No		Yes
Variables	OR	95% CI		p-Value	N	%	N	%
TEVAR	0.61	0.28	1.33	0.22	1148	13.6	7	9.9
Medical	Ref				7307	86.4	64	90.1
Age
18–44	Ref				675	8	11	15.5
45–59	0.69	0.34	1.41	0.31	1901	22.5	21	29.6
60–74	0.71	0.35	1.47	0.36	2949	34.9	30	42.3
≥75	0.23	0.09	0.59	0.00	2930	34.7	9	12.7
Insurance
Medicare	0.63	0.32	1.24	0.18	5189	61.4	31	43.7
Medicaid	Ref				978	11.6	15	21.1
Private insurance	0.93	0.47	1.86	0.84	1732	20.5	23	32.4
Other	0.24	0.06	1.07	0.06	556	6.6	2	2.8

Discussion

The longstanding standard of care for uaTBAD has been OMT via impulse control.¹ With advancements in endovascular therapy and observed shortcomings in OMT long-term outcomes, the roll for TEVAR in treating uaTBAD remains unclear. This is further supported by the 2017 European Society for Vascular Surgery guidelines for thoracic aortic diseases, stating early TEVAR can be a viable treatment in certain circumstances under careful consideration.³⁸

The present study reports U.S. nationwide outcomes for uaTBAD patients who received either OMT or early TEVAR. Of the 12,645 patients, 1543 were treated with TEVAR (12.2%). This corroborates the current common practice of not intervening during the acute setting when possible.^38–40

Importantly, there were differences observed in demographics between the surgical and medical cohorts. TEVAR patients were more often younger, male, and had fewer comorbidities, suggesting clinicians may be carefully selecting patients who they believe may benefit from early TEVAR. The TEVAR cohort was more often admitted to teaching and larger hospitals, which are more likely to have aortic centers—presumably with more TEVAR experience and better resources.

Interestingly, patients undergoing TEVAR had a lower risk of index admission mortality. This differs from Yi, et al.’s findings, whose retrospective multi-institutional study found no difference in mortality between treatment groups for uaTBAD suggesting clinical equipoise.³¹ Perhaps uaTBAD may not be as uncomplicated as its name implies. Progression of dissection while hospitalized may explain OMT’s increased mortality.⁴¹ This study found no difference in 90-day all-cause readmissions or in 90-day readmission for treatment failure between cohorts. Conversely, Yi, et al. found that early TEVAR had lower rates of unplanned readmission (34% vs 9%) and operation (28% vs 8%).³¹ Low rates (TEVAR n = 7, OMT n = 64) likely underpowered the analysis in 90-day treatment failure outcomes, causing the discrepancy. Alternatively, the lack of granularity in the NRD or bias introduced by the experience of their involved centers contributed to this difference.

This study has all the limitations of a retrospective review of a large database, including the inability to obtain more granular data, such as anatomical characteristics, medical management adequacy, and aortic remodeling on follow-up imaging. Additionally, the NRD only follows patients through a single calendar year, preventing us from reporting 90-day readmission data beyond 9 months annually. This likely results in an underestimation of readmission and treatment failure rates. Though nationwide, the NRD only tracks patients within each state. Lastly, utilizing a database carries the well-known risk of inaccurate coding, documentation errors, and missing relevant information.

Conclusions

TEVAR and OMT for uaTBAD had no difference in all-cause and treatment failure 90-day readmissions. Early TEVAR was associated with lower index admission mortality, but higher rates of SCI. However, the cohorts differed in demographics and comorbidities; thus, early TEVAR benefits in this study may reflect patient selection bias. These findings provide further evidence to the equipoise of treatment options and support the need for the randomized trials ongoing in the U.S. and Europe investigating outcomes of TEVAR versus OMT for uaTBAD.

Footnotes

Declaration of conflicting interests

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: EO—none; LD—none; JY—none; GM is a consultant for W.L. Gore & Associates and Cook Medical; SH is a consultant for W. L. Gore & Associates, Cook Medical, and Terumo.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical Approval

This study contains data obtained from the Nationwide Readmissions Database (NRD), which contains publicly available de-identified patient information. Based on institutional review board (IRB) criteria, prior IRB approval and patient consent are not required for this study.

ORCID iDs

Elliott A Orloff

Jeniann Yi

Sukgu M Han

Appendix

Table 8.

Inclusion criteria ICD-10 codes. OMT cohort has any of the listed ICD-10 diagnosis codes without the TEVAR procedure code and the TEVAR cohort is with the TEVAR procedure code.

ICD-10 Code	Description
I71.00	Dissection of unspecified aorta
I71.01	Dissection of thoracic aorta
I71.03	Dissection of thoracoabdominal aorta
02RW4	Thoracic endovascular aortic repair

Table 9.

Exclusion criteria ICD-10 codes. Open repair, chronic etiology, iatrogenic etiology, traumatic etiology, complicated TBAD defined as ruptured/symptoms of malperfusion, and type A aortic dissection defined as ascending/arch repair and heart surgery.

ICD-10 Code	Description
I71.9	Aortic aneurysm, unruptured
S25.00-02, S25.09	Iatrogenic/traumatic thoracic aortic injury
I71.1	Thoracic aortic aneurysm, ruptured
I71.5	Thoracoabdominal aortic aneurysm, ruptured
N17.0, N17.1, N17.2, N17.8, and N17.9	Acute kidney injury, non-traumatic
K55.059	Acute mesenteric ischemia
M62.2	Acute limb ischemia, non-traumatic
02RW0	Descending thoracic aortic repair, open
02RX	Ascending/arch aortic repair
3E080GC	Cardioplegia
02R5-9, 02RD, 02RF, 02RG, 02RH, 02RJ, 02RK, 02RL, and 02RM	Heart valve repair
0210–0213	Coronary vessel surgery

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