Procedure-Associated Costs and Midterm Outcomes of Endovascular Zone 0 and Zone 1 Aortic Arch Repair

Abstract

Thoracic endovascular aortic repair (TEVAR) of proximal aortic arch disease provides a less invasive treatment option for high-risk patients who are not candidates for open arch reconstruction. However, the fiscal impact of these techniques remains unclear. Therefore, our objective was to characterize the midterm outcomes after zone 0 and zone 1 TEVAR and to describe the associated technical costs, technical revenues, and net technical margins at a single tertiary medical center. We examined all patients who underwent TEVAR between April 2011 and August 2019 by retrospective chart review at a single tertiary medical center. Patients were categorized by proximal thoracic endograft extent to identify those with zone 0 or zone 1 landing zones. Procedural characteristics and outcomes were described. Total technical costs, technical revenues, and net technical margins were obtained from the hospital finance department. We identified 10 patients (6 zone 0, 4 zone 1) who had been turned down for open surgical arch reconstruction. Patients were predominantly female (n = 8 [80%]), and the mean age was 72.8 ± 5.5 years. Repair was performed in five asymptomatic patients, urgently in three symptomatic patients and emergently in two ruptured patients. Aortic disease and procedural details are described in the Table. Great vessel debranching with chimney stent grafting was performed in four patients, debranching with branched thoracic endografting in one patient (investigational device exemption clinical trial), and traditional surgical debranching alone in four patients. In situ fenestration was performed in one patient. Within the 30-day postoperative period, one patient experienced a stroke and one patient died. Bypass and branch vessel patency were 100% through the duration of follow-up (mean, 19.3 months). Mean total technical cost associated with all procedures or stages of repair was $105,164 ± $59,338, whereas mean net technical margin was −$25,055 ± $18,746. The net technical margin was negative in the treatment of nine patients. Endovascular repair of the proximal aortic arch is associated with good midterm outcomes in patients considered too high risk for open repair. However, reimbursement does not adequately cover the cost of treatment, with net technical margins being negative in nearly all cases. To remain financially sustainable, efforts should be made to optimize aortic arch TEVAR delivery as well as to advocate for reimbursement commensurate with associated costs.TableProcedural details, outcome measures, and associated technical costs and net technical margins for Zone 0 (n = 6) and Zone 1 (n = 4) TEVARPatientIndication for repairProximal extent of coverageGreat vessel reconstructionNumber of procedures/stagesStroke or deathBypass/Branch patencySurvivalTechnical cost (USD)Net technical margin (USD)1Ruptured aneurysmZone 1Carotid-carotid bypass, LSA embolization1No100%Alive at 31 months; follow-up ongoingN/AN/A2Asymptomatic aneurysmZone 0Carotid-carotid bypass, LSA to L carotid transposition, Gore TSSB branched device to innominate artery3No100%Died of MI 15 months after repair$141,688-$29,5493Type IA endoleak after Zone 2 TEVAR for acute type B dissectionZone 0Carotid-carotid bypass, carotid-LSA transposition, innominate chimney2Death-Died in hospital 4 days after TEVAR$153,668-$45,5984Asymptomatic aneurysmZone 1LSA to carotid transposition, L CCA chimney2No100%Alive at 37 months; follow-up ongoing$115,223-$31,7485Symptomatic aneurysmZone 0Carotid-carotid-LSA bypass, innominate chimney, LSA embolization2Stroke100%Died 18 months after repair$101,317-$20,9286Ruptured dissectionZone 0Carotid-carotid bypass, chimney to innominate, snorkel to LSA2No100%Alive at 34 months; follow-up ongoing$185,613-$54,6227Asymptomatic aneurysmZone 0L carotid to R carotid transposition, L carotid to LSA bypass, LSA embolization2No100%Alive at 23 months; follow-up ongoing$97,579-$18,8878Chronic type B dissection with asymptomatic aneurysmZone 1Carotid-carotid-LSA bypass2No100%Alive at 2 months; follow-up ongoing$48,068-$26,2809Penetrating aortic ulcerZone 0Carotid-carotid-LSA bypass at OSH2 (debranching at OSH)No100%Died 6 months after repair of unknown causes$42,813$4,90210Chronic type B dissection with asymptomatic aneurysmZone 1Left carotid and LSA in situ branched fenestrations1No100%Alive at 8 months; follow-up ongoing$60,505-$2,784CCA, Common carotid artery; LSA, left subclavian artery; MI, myocardial infarction; OSH, outside hospital; TSSB, thoracic single side branch; USD, United States dollars. Open table in a new tab