Protocolized management of acute type B aortic dissections reduces disease progression and need for surgery.

Abstract

Treatment of acute type B aortic dissection (TBAD) is highly variable across institutions, specialties, and practice parameters, with optimal medical therapy (OMT) accepted as both the standard of care and control group for randomized trials. In 2018, our institution developed an acute aortic protocol to standardize care during index acute TBAD presentation. This study aimed to quantify the impact of our institutional protocol. A single-center, retrospective cohort study was performed to include patients who were admitted with acute TBAD over a 12-year period, comparing outcomes before and after protocol initiation. Acute TBAD was defined as a new dissection on imaging with primary, isolated pathology, discovered within 2 weeks of symptom onset. Patients with acute aortic syndrome variants were excluded. Primary outcomes included survival, freedom from aortic surgery, and progression to complicated status. Secondary outcomes included length of stay and periadmission use of oral antihypertensive medications. We used χ² and t tests for categorical and continuous variables, respectively; Kaplan-Meier and log-rank tests were used to assess time to event data. A total of 146 patients were admitted with acute TBAD surrounding protocol implementation: 73 pre protocol and 73 post protocol. Despite no difference in long-term survival (67 vs 88%; P = .16), postprotocol patients had better freedom from aortic surgery (45% vs 75%; P < .001). Additionally, the postprotocol cohort had a lower rate of all (42 vs 22%; P = .01) and aortic-specific (22 vs 8%; P = .004) surgery during primary acute TBAD admission. Protocol initiation resulted in lower rates of progression to complicated dissection at 72 hours (19 vs 5%; P = .03). Implementation of a standardized OMT protocol decreased disease progression in the acute phase and 5-year need for aortic surgery. These data suggest that thoughtful discussions regarding future clinical trial protocolization of OMT and societal standardizations for management are warranted.