Elective interval thoracic endovascular aortic repair versus medical management for uncomplicated type B aortic dissection among Medicare patients

Objective: To compare elective interval thoracic endovascular aortic repair (TEVAR) with ongoing medical management (MM) within 90 days for uncomplicated type B aortic dissection (uTBAD). Methods: Medicare MedPar files from 2001 to 2020 were queried for patients with acute uTBAD who were discharged after index hospitalization without operative intervention. The exposure was elective interval TEVAR versus MM within the first 90 days. Outcomes were overall survival, aortic reintervention, and reintervention-free survival. Propensity score matching, Kaplan-Meier analysis and Fine-Gray regression landmarking at 90 days were used. Results: In total, 23,697 patients were discharged without surgical intervention after admission for acute uTBAD. Within 90 days from diagnosis, 22,857 patients underwent MM, 399 elective TEVAR, and 441 emergent/urgent TEVAR. Matching between MM and elective TEVAR resulted in a well-balanced nearly 27:1 match with 10,608 patients in the MM cohort and 399 in the elective TEVAR cohort. The mean age was 73.5 years, and 51% of patients were female. 90-day mortality was 10.4% for MM and 4.3% for elective TEVAR. Landmarking at 90 days, there was no associated difference in overall survival with 5-year mortality of ∼63%. Similarly, there was no associated difference in reintervention-free survival. The 5-year cumulative incidence of aortic reintervention for MM was 11% and for TEVAR was 14% (P = .04). Conclusions: Among Medicare patients with acute uTBAD, there was no associated difference in overall survival or reintervention free survival between ongoing MM and elective interval TEVAR within 90 days.