Acute Aortic Dissection: Observational Lessons Learned From 11 000 Patients.

BACKGROUND

Over the past 25 years, diagnosis and therapy for acute aortic dissection (AAD) have evolved. We aimed to study the effects of these iterative changes in care.

METHODS

Patients with nontraumatic AAD enrolled in the International Registry of Acute Aortic Dissection (61 centers; 15 countries) were divided into time-based tertiles (groups) from 1996 to 2022. The impact of changes in diagnostics, therapeutic care, and in-hospital and 3-year mortality was assessed. Cochran-Armitage trend and Jonckheere-Terpstra tests were conducted to test for any temporal trend.

RESULTS

Each group consisted of 3785 patients (mean age, ≈62 years old; ≈65.5% males); nearly two-thirds had type A AAD. Over time, the rates of hypertension increased from 77.8% to 80.4% (=0.002), while smoking (34.1% to 30.6%, =0.033) and atherosclerosis decreased (25.6%-16.6%; <0.001). Across groups, the percentage of surgical repair of type A AAD increased from 89.1% to 92.5% (<0.001) and was associated with decreased hospital mortality (from 24.1% in group 1 to 16.7% in group 3; <0.001). There was no difference in 3-year survival (=0.296). For type B AAD, stent graft therapy (thoracic endovascular aortic repair) was used more frequently (22.3%-35.9%; <0.001), with a corresponding decrease in open surgery. Endovascular in-hospital mortality decreased from 9.9% to 6.2% (=0.003). As seen with the type A AAD cohort, overall 3-year mortality for patients with type B AAD was consistent over time (=0.084).

CONCLUSIONS

Over 25 years, substantial improvements in-hospital survival were associated with a more aggressive surgical approach for patients with type A AAD. Open surgery has been partially supplanted by thoracic endovascular aortic repair for complicated type B AAD, and in-hospital mortality has decreased over the time period studied. Postdischarge survival for up to 3 years was similar over time.