April 21, 2026

Study Highlights Insurance-Based Disparities in TEVAR for TBAD

April 21, 2026—In this retrospective analysis, Zil-E-Ali et al found that patients with government-funded insurance who underwent urgent or emergent thoracic endovascular aortic repair (TEVAR) for type B aortic dissection (TBAD) presented with more advanced disease and experienced significantly higher short- and long-term mortality than commercially insured patients. Results were published in the Annals of Vascular Surgery.¹

KEY FINDINGS

Patients with government-funded insurance presented with more advanced TBAD, including higher rates of aortic rupture and emergent intervention.
Government insurance was independently associated with higher in-hospital and 30-day mortality after TEVAR.
Short- and long-term mortality rates were significantly higher among government-insured patients compared with those with commercial insurance.
Within the government-insured cohort, Medicare patients had worse outcomes than Medicaid patients, including higher 1-year mortality.

The United States health insurance system is funded by multiple payers, with private insurers accounting for roughly half of total health care spending and Medicare and Medicaid each contributing approximately 20%. Patients eligible for these government-based insurance plans are generally elderly with multiple coexisting comorbidities or belong to low socioeconomic status and therefore have less access to preventive care, placing these patients at a high risk for presenting with the most advanced form of disease and have poorer outcomes in general, noted the investigators.

Investigators used the Society for Vascular Surgery Vascular Quality Initiative (VQI) database to identify patients who had undergone nonelective TEVAR for TBAD limited to aortic zones 3 and 4 from 2011 to 2021. Patients were stratified into two groups by insurance status: (1) those with government-based coverage (Medicare, Medicaid, or Medicare Advantage) and (2) those with commercial insurance. A subgroup analysis further compared Medicare/Medicare Advantage with Medicaid beneficiaries within the government-insured cohort.

Baseline variables included age, sex, race, body mass index, functional status, comorbidities, prior vascular procedures, medication use, dissection acuity, rupture status, urgency of repair, and American Society of Anesthesiologists class. Primary outcomes were in-hospital, 30-day, and 1-year mortality. Secondary outcomes included postoperative myocardial infarction, respiratory complications, dialysis, reintervention, length of stay, intensive care unit stay, and discharge disposition. Multivariable logistic regression was used to identify factors independently associated with 30-day and in-hospital mortality.

A total of 1,862 patients underwent urgent or emergent TEVAR for TBAD, including 960 (51.6%) patients with government-based insurance and 902 (48.4%) patients with commercial insurance. Government-insured patients were older (65.1 ± 14.1 vs 57.7 ± 12.2 years), more likely to be female, and more functionally dependent and had higher rates of hypertension, diabetes, chronic obstructive pulmonary disease, dialysis dependence, and congestive heart failure. In addition, they more frequently presented with rupture (12.5% vs 7.8%) and underwent emergent repair (39.9% vs 34.6%).

Postoperatively, government-insured patients had worse outcomes across multiple time points. In-hospital mortality was 9.7% versus 5.3%, 30-day mortality was 9.8% versus 5.9%, and 1-year mortality was 17.8% versus 9.5% for government versus commercial insurance, respectively. Government-insured patients also had higher rates of respiratory complications (14.4% vs 10.8%) and postoperative dialysis (8.4% vs 4.6%) and were more often discharged to rehabilitation or skilled nursing facilities rather than home.

On multivariable analysis, government insurance remained independently associated with both 30-day mortality (adjusted odds ratio [aOR], 1.85; 95% CI, 1.16-2.94; P = .010) and in-hospital mortality (aOR, 2.38; 95% CI, 1.04-5.44; P = .040). Other predictors of worse mortality included severe congestive heart failure, chronic obstructive pulmonary disease, aortic rupture, diabetes mellitus, and emergent operation. Preoperative angiotensin-converting enzyme inhibitor use was associated with lower in-hospital mortality (aOR, 0.32; 95% CI, 0.17-0.60; P < .001).

Within the government-insured cohort, Medicare patients had worse outcomes than Medicaid patients, including higher in-hospital mortality (11% vs 6.2%), 30-day mortality (11.1% vs 6.2%), and 1-year mortality (20.3% vs 11.2%).

Investigators noted several limitations, including the retrospective design, inability to establish causality, potential residual confounding, lack of granular clinical detail on malperfusion severity, inability to distinguish spontaneous from traumatic dissections, classification by primary payer only, and the self-reported nature of the VQI registry.

This analysis suggests that insurance type is an important marker of risk among patients undergoing nonelective TEVAR for TBAD. Government-insured patients, particularly Medicare beneficiaries, presented with more severe disease and experienced substantially worse perioperative and 1-year outcomes, underscoring the role of social determinants of health, preventive care gaps, and access disparities in acute aortic care.

1. Zil-E-Ali A, So KL, Choi ES, Aziz F. Health insurance payor type as a predictor of clinical presentation and mortality in patients undergoing urgent or emergent TEVAR for type B aortic dissection: insights from Society for Vascular Surgery Vascular Quality Initiative Database. Ann Vasc Surg. 2026;127:264-273. doi: 10.1016/j.avsg.2026.02.007

ENDOVASCULAR TODAY ASKS...

Study investigators Ahsan Zil-E-Ali, MD, research fellow, and Faisal Aziz, MD, MBA, FACS, DFSVS, Chief of Vascular Surgery, Pennsylvania State University in Hershey, Pennsylvania, further discuss the study’s findings, the role that social determinants of health play in this patient population, and improvements needed to address gaps in care.

Your study identifies insurance type as an independent predictor of mortality. How should vascular surgeons incorporate this information into preoperative risk stratification and patient counseling for urgent TEVAR?

From our study, insurance type can be best interpreted as a surrogate for a broader, multidimensional risk profile rather than an isolated variable. Government-insured patients in our cohort were older, more functionally dependent, and carried significantly higher burdens of hypertension, diabetes, chronic obstructive pulmonary disease, and congestive heart failure, all of which independently contribute to worse perioperative outcomes. In the urgent and emergent setting, insurance status should serve as a clinical prompt to more rigorously assess physiologic reserve and calibrate operative decision-making accordingly.

Patients with government-funded insurance presented with more advanced disease. What do you see as the key drivers of delayed presentation in this population, and how can earlier detection be improved?

The drivers of delayed presentation are largely structural, rooted in limited access to primary and preventive care, gaps in chronic disease management, and reduced utilization of health care resources when warranted. Addressing this will require efforts well beyond the hospital setting, including more rigorous hypertension control in underserved communities, expanded access to vascular specialty care, and integration of risk-based aortic screening protocols into primary care practices that disproportionately serve government-insured populations.

What targeted strategies (at the health system or policy level) do you believe could most effectively reduce the disparities in presentation and outcomes observed between government- and commercially insured patients?

Reducing these disparities will require coordinated action at both the health system and policy levels. At the system level, improving chronic disease management, increasing specialist access in underserved areas, and standardizing care pathways for high-risk aortic patients could meaningfully narrow outcome gaps. At the policy level, addressing reimbursement structures that disincentivize care in government-insured populations and expanding coverage for preventive vascular services are critical steps. Sustainable improvement will ultimately depend on embedding equity-focused metrics into institutional quality improvement frameworks.

Your findings highlight systemic gaps in care, including chronic disease management and access to preventive services. What interventions do you think are most critical to address these gaps and optimize perioperative outcomes in high-risk populations?

Upstream, improved management of modifiable risk factors, particularly chronic conditions in the primary care setting, remains foundational. At the institutional level, early multidisciplinary involvement, alongside adherence to evidence-based protocols, is essential. Based on our findings, systematically identifying government-insured patients as an inherently vulnerable subgroup and tailoring perioperative pathways to their elevated risk profile is a practical, actionable step institutions can implement within existing frameworks.

Given the worse outcomes observed among Medicare patients compared with Medicaid patients, how should clinicians and health systems tailor postoperative surveillance and follow-up care for these particularly vulnerable patients?

The differential outcomes between Medicare and Medicaid beneficiaries likely reflect the older age, comorbidity burden, and diminished physiologic reserve that characterize the Medicare population. Clinicians should apply heightened postoperative vigilance to this subgroup, incorporating structured surveillance intervals, lower thresholds for reintervention, and proactive coordination with primary care for ongoing medical optimization. At the health system level, dedicated transitional care programs and expansion of telemedicine-based surveillance represent practical strategies to mitigate the disproportionate burden of late mortality observed in this cohort.

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