Local Community Socioeconomic Deprivation Affects Survival After Acute Ascending Aortic Dissection Repair

J. Awtry¹, T. Faggion Vinholo², A. Gikandi³, S. McGurk⁴, M. Cunningham⁴, A. Itoh⁴, G. Tolis⁴, A. Sabe⁴, K. De La Cruz^5
1Brigham and Women's Hospital, Brookline, Massachusetts ²Brigham & Women’s, Boston, Massachusetts ³Harvard Medical School, Brighton, Massachusetts ⁴Brigham and Women's Hospital, Boston, Massachusetts ⁵Brigham and Women's Hospital, Newton, Massachusetts

Purpose: Ascending thoracic aortic dissection is a surgical emergency requiring resource-intensive acute management and follow up care. However, research assessing the impact of community resource availability on outcomes after acute aortic dissection has been limited.1 We therefore interrogated the relationship between community socioeconomic disadvantage and outcomes after ascending aortic dissection repair.

Methods: Consecutive patients with a Debakey Type I/II dissection from 2002-2020 at a single aortic referral center were included. Type III dissection, chronic dissection, or dissection secondary to trauma were excluded. Patients were stratified into quartiles based on the area deprivation index (ADI)2 of their home address. The ADI measures community socioeconomic disadvantage by incorporating local income, education, employment, and housing quality into a composite assessment of community resources with fine geographic resolution. Outcomes were compared across quartiles and between patients with low ADI (most resources; defined as the 1st quartile in the cohort) and high ADI (fewer resources; 2nd-4th quartiles). Primary outcomes were operative mortality and long-term survival. Secondary outcomes included perioperative morbidity and aortovascular reoperation. Multivariate cox proportional hazard (PH) modeling and competing risk analyses assessed adjusted long-term survival and reoperation, respectively.

Results: Overall, 295 patients were identified. Median follow up time was 3.7 years. In the overall cohort average age was 61.6±13.5 years, 27.8% (75/295) of patients were non-White, 34.6% (105/295) were female, median[IQR] national ADI was 22[14,31], median distance to the operative hospital was 19.3[10.5,37.1] miles, and 78% (230/295) were transferred. Patients with higher ADI were more likely to be transferred from another hospital (46/73, 64.8% vs 65/76, 85.5% vs 60/76, 78.9% vs 59/70, 84.3% for the 1st-4th quartiles, p=0.009), though baseline demographics, clinical presentation, and operative details were otherwise similar across quartiles. There were no differences in perioperative mortality or morbidity across quartiles (all p>0.05). When comparing the low vs high ADI groups 30-day mortality remained similar (6/73, 8.2% vs 31/222, 14%; odds ratio 0.56[0.20,1.22]; p=0.20), however low ADI patients had significantly improved long-term survival (multivariate Cox PH hazard ratio=0.53[0.31,0.91], p = 0.022; see Figure). Age (HR=1.04[1.02,1.06]), type II dissection (HR=2.04[1.26,3.32]), and malperfusion on presentation (HR=2.48[1.54,4.01]) were associated with long-term mortality, while transfer from another hospital and home distance from the hospital were not. There was no significant difference in aortovascular reoperation between low and high ADI groups (5-year estimated incidence 24% vs 18%, Gray’s test p=0.46).

Conclusion: Patients living in areas of greater socioeconomic deprivation have decreased long-term survival after ascending aortic dissection repair. Targeted interventions are needed to improve outcomes after dissection repair in these areas and should be considered in the context of care system shifts toward greater regionalization.3

Identify the source of the funding for this research project: None