Endovascular repair in aortic dissection: Superior outcomes and cost-effectiveness in a contemporary cohort

Background Aortic dissection is a life-threatening condition requiring urgent intervention, with treatment options including open surgical repair, endovascular procedures, or intensive medical management. This study compares outcomes across these strategies using a national cohort. Methods We analyzed data from the National Inpatient Sample (2018–2022), identifying 83,075 hospitalizations nationally. Survey-weighted logistic regression models estimated crude and adjusted odds ratios (ORs) for mortality and moderate disability, comparing open repair, endovascular procedures, and no procedure. Adjustments included age, sex, race, income, comorbidities, and hospital characteristics. We also evaluated procedure incidence, length of stay (LOS), total charges, and complications. Results Of the weighted hospitalizations, 2.5% underwent open repair, 18.1% received endovascular procedures, and 79.5% had no procedure. Endovascular procedures were associated with significantly lower mortality (adjusted OR: 0.43, 95% CI: 0.36–0.51, p<0.001) and moderate disability (43.2% vs. 69.4% for open repair, p<0.001) compared to no procedure, while open repair showed higher mortality (adjusted OR: 1.45, 95% CI: 1.05–2.00, p=0.023) and disability. Mortality rates were 12.9% for no procedure, 14.0% for open repair, and 5.2% for endovascular procedures. LOS and total charges were highest for open repair (mean LOS: 15.6 days, mean charges: $513,367) compared to endovascular (10.2 days, $363,585) and no procedure (9.2 days, $253,141). Timing analysis indicated lower mortality for endovascular procedures performed after day 1 (intermediate [days 2–3]: adjusted OR: 0.45, p=0.024; late [>3 days]: adjusted OR: 0.51, p=0.029) compared to early intervention (day 1). For open repair, timing showed no significant mortality difference (intermediate: adjusted OR: 0.23, p=0.236; late: adjusted OR: 0.23, p=0.079) compared to early intervention. Complications, including acute myocardial infarction and shock, were less frequent with endovascular procedures. Conclusion Endovascular procedures are associated with lower mortality, disability, LOS, and costs compared to open repair or medical management in aortic dissection patients. These findings support the preferential use of endovascular approaches, particularly when timed after initial stabilization (beyond day 1), to optimize outcomes. Intensive blood pressure and heart rate control may enhance survival when paired with delayed endovascular intervention.