Superior Nationwide Outcomes of Endovascular versus Open Repair for Isolated Descending Thoracic Aortic Aneurysm in 11,669 Patients

Abstract

Conclusion: Compared with open aortic repair (OAR) thoracic endovascular aneurysm repair (TEVAR) is associated with shorter hospital stay, similar mortalities, fewer complications, and increased hospital charges. Summary: The first endovascular prosthesis was approved in 2005 for thoracic endovascular aneurysm repair in the United States. The technology has been widely adopted but there is little information available on TEVAR nationwide outcomes for treatment of descending isolated thoracic aortic aneurysm (TAA). The authors therefore compared in hospital outcomes of TEVAR and open descending TAA repairs performed in the United States during the initial 3 years following approval of the GORE TAG device. They used nationwide data to identify patients who had undergone surgery for isolated descending TAA from 2006-2007. Patients treated for aortic dissection or rupture or who underwent simultaneous treatment of other aortic segments were excluded. There were 11,669 patients analyzed and 9,106 had conventional open aneurysm repair (OAR) and 2,563 had TEVAR. Patients were compared for mortality and hospital stay as well as discharge status, morbidity, and hospital charges. Patients undergoing TEVAR were older (69.5 ± 12.7 versus 60.2 ± 14.2 years; P < .001) and had higher preoperative morbidity. Length of stay was shorter for TEVAR patients (7.7 ± 11 versus 8.8 ± 7.9 days). Unadjusted mortality was similar for TEVAR (2.3%) and OAR (2.2%; P = 1.0). There were similar proportions of non elective interventions in the two groups (TEVAR 15.9% versus OAR 15.8%; P = .9). Risk adjusted mortality rates with TEVAR and OAR were similar. TEVAR patients, however, had 60% fewer complications (OR, 0.39; P < .001). TEVAR patients were 4 times more likely to have a routine discharge home than OAR patients. TEVAR hospital charges were greater by $6713 (95% CI, 1869- 11,556; P < .001). Comment: Surgical procedures with good outcomes and that are “easy” to perform are adopted widely. More difficult procedures are generally restricted to high volume centers. Wide spread adoption of TEVAR is appropriate. Even though TEVAR was selectively performed in patients almost a decade older than the OAR patients, outcomes were comparable, if not superior, for TEVAR versus OAR with TEVAR having significantly better risk adjusted morbidity, primarily from lower incidences of neurologic, respiratory and pulmonary complications. Additional data is needed to determine whether TEVAR has volume dependent outcomes, or like endovascular abdominal aortic aneurysm repair, can be performed with relatively low morbidity in low volume hospitals. Such data is needed to determine whether thoracic aortic aneurysm patients should be treated in centers dedicated to treatment of aortic disease or if TEVAR will permit more wide spread treatment of thoracic aortic pathology in community and smaller regional hospitals.