A clinical decision model for selecting the most appropriate therapy for uncomplicated chronic dissections of the descending aorta

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Abstract

Objective:

The optimal treatment for patients with uncomplicated chronic Stanford type B aortic dissections (chTBADs) is still matter of debate. The purpose of this study was to design a decision tool to guide the surgeon in determining the preferred treatment option.

Methods:

A Markov decision-analysis model compared chTBAD patients treated with initial open surgical repair (OSR), thoracic endovascular aortic repair (TEVAR), and optimal medical therapy (OMT), followed during follow-up by OSR (OMT-OSR) or TEVAR (OMT-TEVAR), if indicated. Procedural risks, aortic growth and rupture rates, outcomes, and quality of life values were derived from the best available evidence in the literature. A chTBAD treatment strategy decision tool was developed, including the four key variables of age, sex, surgical risk, and maximum initial aortic diameter. Primary outcome was quality-adjusted life-years (QALYs).

Results:

For the reference patient cohort, 55-year-old men with chTBAD with a maximum aortic diameter of 5.0 cm, medium risk for surgery, and a threshold for surgery of 6.0 cm during follow-up, OSR yielded higher QALYs, with 10.06 QALYs (95% credibility interval [CI], 9.52-10.56 QALYs) vs 9.92 QALYs (95% CI, 9.23-10.58 QALYs) after TEVAR and 9.64 QALYs (95% CI, 9.38-9.88 QALYs) and 9.40 QALYs (95% CI, 9.11-9.69 QALYs) for OMT-OSR and OMT-TEVAR. The difference between OSR and OMT-OSR was 0.42 QALYs (95% CI, 0.01-0.81 QALYs) and between TEVAR and OMT-TEVAR was 0.52 QALYs (95% CI, 0.04-0.68 QALYs). This showed that intervention is preferred over OMT. A change of the four variables resulted in a change of preferred treatment. In general, OSR was the preferred treatment in younger patients with a larger aortic diameter and in low-risk patients. TEVAR was preferred in elderly patients with large aortic diameter and if the aortic diameter threshold for repair decreased. OMT was the optimal therapy in high-risk patients, elderly patients, or in patients with small aortic diameters.

Conclusions:

This decision-analysis model shows that there is no “one-size-fits-all” treatment for uncomplicated chTBADs. For the reference patient cohort, intervention is preferred over OMT. Age is the most important deciding factor, followed by initial aortic diameter. Immediate OSR is the preferred treatment option in younger patients with a large initial aortic diameter and in low-risk patients. Immediate TEVAR is preferred in elderly patients with a large initial aortic diameter and in patients with a lower threshold for OSR. OMT should be considered in high-risk patients, in patients with small initial aortic diameters, and in patients aged >80 years, unless their initial aortic diameter is >5.5 cm. However, the differences in some patient groups are clinically insignificant, allowing a major role for patient preferences and hospital-specific considerations. This clinical decision model may guide chTBAD treatment.

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