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Surveillance Imaging Following Acute Type A Aortic Dissection
Quick Takes
- In a population-based administrative health database study, compliance with ACCF/AHA guidelines for follow-up imaging among patients who survived acute type A aortic dissection repair was poor (21% at 2 years, 3.9% at 6 years, <2% at 8 years).
- Adherence to guideline imaging recommendations was weakly but statistically significantly associated with aortic reintervention (HR, 1.04; 95% CI, 1.01-1.07), but also with worse mortality (HR, 1.0; 95% CI, 1.05-1.11).
Study Questions:
Among survivors of acute type A aortic dissection (ATAAD) repair, what is the frequency of postoperative surveillance imaging, and what are long-term outcomes?
Methods:
Population-based administrative health databases for Ontario, Canada, were linked to identify patients who underwent ATAAD repair and survived at least 90 days. Guideline-directed surveillance imaging was defined as undergoing a computed tomographic or magnetic resonance imaging scan at 6 and 12 months postoperatively and then annually thereafter. Multivariable time-to-event analysis was used to assess the associations between guideline-directed surveillance imaging and all-cause mortality and reintervention.
Results:
The study cohort consisted of 888 patients who survived urgent ATAAD repair April 2005–March 2018. Median follow-up after ATAAD repair was 5.2 years (interquartile range, 2.4-7.9 years). A total of 14% of patients underwent guideline-directed surveillance imaging throughout follow-up; with the proportion of compliance dropping quickly to 21% at 2 years, 3.9% at 6 years, and <2% at 8 years after ATAAD repair. The mortality rate was 4% at 1 year, 14% at 5 years, and 29% at 10 years. The incidence of aortic reintervention was 3% at 1 year, 9% at 5 years, and 17% at 10 years; the majority of these were urgent (68%), and reintervention carried a 30-day mortality rate of 9%. Risk factors for mortality included increased age (hazard ratio [HR], 1.05; 95% confidence interval [CI], 1.03-1.07), higher Charlson comorbidity index (HR, 1.29; 95% CI, 1.10-1.50), chronic kidney disease (HR, 1.97; 95% CI, 1.01-3.86), and the lowest quintile of neighborhood income (HR, 1.61; 95% CI, 1.01-2.57); whereas female sex was a protective factor (HR, 0.66; 95% CI, 0.45-0.95). On multivariable analysis, there was a positive correlation between greater adherence to guideline-directed surveillance imaging and mortality (HR, 1.08; 95% CI, 1.05-1.11) and reintervention (HR, 1.04; 95% CI, 1.01-1.07).
Conclusions:
The adherence to guideline-directed surveillance imaging following ATAAD repair is poor, and long-term mortality and reinterventions remain substantial despite routine imaging. The authors concluded that further research is needed to determine if guidelines should be modified.
Perspective:
Patients who undergo repair of ATAAD are at risk for progressive dilation and rupture of the retained native aorta. With the caveat that supporting data were absent, the 2010 American College of Cardiology Foundation/American Heart Association (ACCF/AHA) Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease recommend surveillance imaging among patients who undergo aortic repair at discharge; at 1, 3, 6, and 12 months postoperatively; and then annually (Class IIa, Level of Evidence C; J Am Coll Cardiol 2010;55:e27-129 [doi:10.1016/j.jacc.2010.02.015]). This population-based administrative database study from Ontario, Canada, suggests that adherence to those recommendations is low even by 2 years after intervention, and that adherence to imaging recommendations was weakly but statistically significantly associated with reintervention but also with worse mortality. Although limited as an administrative database study and by low numbers of patients who met compliance criteria with imaging guidelines, the study suggests that data to support the imaging guidelines should be sought, and that the guideline recommendations potentially should be rethought.
Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Vascular Medicine, Aortic Surgery, Interventions and Imaging, Interventions and Vascular Medicine, Computed Tomography, Magnetic Resonance Imaging, Nuclear Imaging
Keywords: Aneurysm, Dissecting, Aortic Diseases, Cardiac Surgical Procedures, Cardiology Interventions, Comorbidity, Diagnostic Imaging, Dilatation, Magnetic Resonance Imaging, Patient Discharge, Renal Insufficiency, Chronic, Risk Factors, Survivors, Tomography, X-Ray Computed, Vascular Diseases
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