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

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A clinical decision model for selecting the most appropriate therapy for uncomplicated chronic dissections of the descending aorta Wouter Hogendoorn, MD, M.G. Myriam Hunink, MD, PhD, Felix J.V. Schlösser, MD, PhD, Frans L. Moll, MD, PhD, Bauer E. Sumpio, MD, PhD, Bart E. Muhs, MD, PhD Journal of Vascular Surgery Volume 60, Issue 1, Pages 20-30 (July 2014) DOI: 10.1016/j.jvs.2014.01.054 Copyright © 2014 Society for Vascular Surgery Terms and Conditions

Fig 1 Simplified bubble diagram shows interaction between health states for treatment of chronic type B aortic dissection (chTBAD). Each health state has a possible transition to itself, which is not shown in this figure for clarity. TEVAR, Thoracic endovascular aortic repair. Journal of Vascular Surgery 2014 60, 20-30DOI: (10.1016/j.jvs.2014.01.054) Copyright © 2014 Society for Vascular Surgery Terms and Conditions

Fig 2 Total expected quality-adjusted life-years (QALYs) at age of presentation of (A) 50 to 70 years and (B) 70 to 90 years. Thresholds indicate change in preferred treatment strategy: open surgical repair (OSR), ≤60 years; thoracic endovascular aortic repair (TEVAR), 60 to ≤70 years; and optimal medical therapy (OMT) >70 years. OMT followed by TEVAR (OMT-TEVAR) and OMT followed by OSR (OMT-OSR) are exactly equal in panel (B). Journal of Vascular Surgery 2014 60, 20-30DOI: (10.1016/j.jvs.2014.01.054) Copyright © 2014 Society for Vascular Surgery Terms and Conditions

Fig 3 This treatment strategy decision chart indicates optimal treatment strategy on the basis of four basic characteristics: age, sex, surgical risk profile, and maximum initial aortic diameter. Two treatment strategies in the same cell (OSR/TEVAR, TEVAR/OMT, and OSR/OMT) indicate a difference of <2 months in quality-adjusted life-years (QALYs). No diff indicates a difference of <2 months for all the treatment groups. The dotted box is the reference case. TEVAR, Thoracic endovascular aortic repair. Journal of Vascular Surgery 2014 60, 20-30DOI: (10.1016/j.jvs.2014.01.054) Copyright © 2014 Society for Vascular Surgery Terms and Conditions

Fig 4 Total expected quality-adjusted life-years (QALYs) per risk profile of reference-case patient, a 55-year-old man. Low-risk patient: relative risk (RR), 0.5; medium-risk: RR, 1.0; high-risk: RR, 2.0. Increase of the patient's risk profile shows a shift from open surgical repair (OSR) to thoracic endovascular aortic repair (TEVAR). OMT-OSR, Optimal medical therapy followed by OSR; OMT-TEVAR, OMT followed by TEVAR. Journal of Vascular Surgery 2014 60, 20-30DOI: (10.1016/j.jvs.2014.01.054) Copyright © 2014 Society for Vascular Surgery Terms and Conditions

Fig 5 Total expected quality-adjusted life years (QALYs) for maximum initial aortic size (in cm) of reference-case patient, a 55-year-old man with chronic type B aortic dissection (chTBAD). Increase of the maximum initial aortic diameter shows shift from optimal medical therapy (OMT) to intervention by open surgical repair (OSR) or thoracic endovascular aortic repair (TEVAR). OMT-OSR, OMT followed by OSR; OMT-TEVAR, OMT followed by TEVAR. Journal of Vascular Surgery 2014 60, 20-30DOI: (10.1016/j.jvs.2014.01.054) Copyright © 2014 Society for Vascular Surgery Terms and Conditions

Fig 6 Total expected quality-adjusted life-years (QALYs) for treatment of chronic type B aortic dissection (chTBAD) in the reference-case patient (a 55-year-old man) with open surgical repair (OSR), thoracic endovascular aortic repair (TEVAR), and optimal medical therapy (OMT) per quality of life (QOL) for conservative treated patients. Expected QALYs for OSR are always higher than for TEVAR and OMT, and only OMT is affected by QOL for conservative treatment. Journal of Vascular Surgery 2014 60, 20-30DOI: (10.1016/j.jvs.2014.01.054) Copyright © 2014 Society for Vascular Surgery Terms and Conditions