Survival After Open Versus Endovascular Thoracic Aortic Aneurysm Repair in an Observational Study of the Medicare PopulationClinical Perspective
Background—The goal of this study was to describe short- and long-term survival of patients with descending thoracic aortic aneurysms (TAAs) after open and endovascular repair (TEVAR).
Methods and Results—Using Medicare claims from 1998 to 2007, we analyzed patients who underwent repair of intact and ruptured TAA, identified from a combination of procedural and diagnostic International Classification of Disease, ninth revision, codes. Our main outcome measure was mortality, defined as perioperative mortality (death occurring before hospital discharge or within 30 days), and 5-year survival, from life-table analysis. We examined outcomes across repair type (open repair or TEVAR) in crude, adjusted (for age, sex, race, procedure year, and Charlson comorbidity score), and propensity-matched cohorts. Overall, we studied 12 573 Medicare patients who underwent open repair and 2732 patients who underwent TEVAR. Perioperative mortality was lower in patients undergoing TEVAR compared with open repair for both intact (6.1% versus 7.1%; P=0.07) and ruptured (28% versus 46%; P<0.0001) TAA. However, patients with intact TAA selected for TEVAR had significantly worse survival than open patients at 1 year (87% for open, 82% for TEVAR; P=0.001) and 5 years (72% for open; 62% for TEVAR; P=0.001). Furthermore, in adjusted and propensity-matched cohorts, patients selected for TEVAR had worse 5-year survival than patients selected for open repair.
Conclusions—Although perioperative mortality is lower with TEVAR, Medicare patients selected for TEVAR have worse long-term survival than patients selected for open repair. The results of this observational study suggest that higher-risk patients are being offered TEVAR and that some do not benefit on the basis of long-term survival. Future work is needed to identify TEVAR candidates unlikely to benefit from repair.
Given the significant risk involved with descending thoracic aortic aneurysm (TAA) repair and the incidence of medical comorbidities in the patients who present with these lesions, surgeons have struggled to balance the probability of death resulting from aneurysm rupture with the risk of surgical intervention.1–4 The introduction of thoracic endovascular repair (TEVAR) has further complicated this relationship5–7 because this less invasive intervention has expanded the pool of patients who are physiological candidates for surgery. Subsequently, single-center, regional, and national studies have described a significant increase in the use of TEVAR, with a significant short-term benefit in perioperative mortality.5–10
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However, long-term survival after TAA repair in real-world clinical practice remains uncertain. Although several reports have described similar midterm survival after open repair and TEVAR, these studies have been limited to single-institution series from centers of excellence or results from industry-sponsored trials and registries11–14; only 1 clinical trial has reported 5-year outcomes. Furthermore, few population-based data describing TEVAR and open repair are available that allow examination of survival differences for distinct TAA, especially across rupture status at presentation or by repair type.5
Therefore, we sought to compare perioperative and long-term mortality in the contemporary, real-world practice of open repair and TEVAR. We studied all patients undergoing open repair and TEVAR in recent years in the US Medicare population and examined the short- and long-term survival with these procedures.
Establishing a Cohort of Patients Who Underwent Repair of TAA
We used the Medicare Physician/Supplier File and the Medicare Denominator File for these analyses for the years 1998 to 2007. First, we created a cohort of patients who underwent a broad range of thoracic aortic procedures, as defined by the International Classification of Disease, ninth revision (ICD-9), codes in Table 1.15 Next, we selected from this cohort those patients who underwent TEVAR and open repair of TAA. As outlined in Figure 1, we eliminated all claims that were not contained in the Medicare Denominator File and patients <66 years of age. We required patients to have at least 1 year of Medicare eligibility before surgery and used this time period to establish comorbidities and to construct patient-specific Charlson scores.16 The Charlson score contains 19 categories of comorbidity based on ICD-9 diagnosis and procedure codes and has been validated in a variety of settings for use in administrative data sets.17,18 Details regarding the components of the Charlson score and the assigned ICD-9 codes are outlined in Table I in the online-only Data Supplement. Furthermore, we eliminated any claim wherein the patient's Medicare health insurance number had changed during the study period because this would not allow survival analysis.
In addition to the procedural codes for TAA, we required that each patient have a diagnosis code for TAA. Initially, we studied 5 distinct diagnoses, as indicated by their respective ICD-9 diagnosis codes (Table 1). We excluded any patient with diagnosis codes for ascending TAA or with procedural codes for cardiopulmonary bypass occurring with circulatory arrest. Furthermore, we excluded patients with thoracoabdominal aneurysms, thoracic aortic dissections, and other aortic pathology from our analysis because these entities are clinically distinct from TAA. Finally, we also excluded patients with ICD-9 procedural codes that may indicate the presence of debranching or other procedures to extend endovascular landing zones such as 39.24 (aortorenal bypass) and 39.25 (aorta-iliac-femoral bypass). In situations in which we encountered >1 procedure (open repair or TEVAR) per patient, we assigned the patient to the first procedure performed.
Finally, we examined the effect of changes in practice pattern over time in 2 ways. First, in prior work,10 we demonstrated that between 1998 and 2003, a significant increase in the use of TEVAR occurred. Before 2003, <10% of all intact TAAs were repaired with TEVAR. After 2003, >10% of all intact TAAs were repaired with TEVAR; this rate grew to 27% by 2007. Therefore, to avoid any bias introduced by the era (before or after introduction of TEVAR), we generated a binary variable (era of procedure) representing the time period during this learning curve (before January 1, 2004) and after this learning curve (after January 1, 2004).
Second, the Food and Drug Administration (FDA) approved a device specifically for use in TEVAR in 2005.19 Therefore, to examine any effect secondary to changes in patient selection after FDA approval, we examined results before and after January 1, 2005, for both open and endovascular repair.
Once we established a cohort of patients with diagnosis codes and procedural codes for TAA repair, we followed them over time to establish our 2 main outcome measures: perioperative and long-term survival using 1- and 5-year survival rates. First, to define perioperative mortality, we sought to capture all deaths occurring in the period after surgery. We defined perioperative mortality as death occurring within the index hospitalization (regardless of postoperative day) and any death within 30 days (regardless of inpatient or outpatient status). The outcome of perioperative death was a binary categorical variable and was analyzed with χ2 tests.
Second, survival at 1 and 5 years was established with the Medicare Denominator File to establish the date of death. We censored those patients who survived until the end of our analysis (at December 31, 2007). Survival curves were estimated with Kaplan-Meier analysis, and life-table analysis was used to establish rates of 5-year survival with surrounding 95% confidence intervals (CIs). Log-rank tests were used to determine significant differences in survival between groups. Values of P<0.05 were considered significant.
Risk-Adjusted and Propensity-Matched Comparisons
To account for differences in patient characteristics between the open repair and TEVAR cohorts, we performed 2 additional analyses. First, we used a survivor function wherein age, sex, race, era of procedure, and Charlson score16 were adjusted with a Cox proportional hazards model to estimate survival. This allowed comparison of survival estimates, adjusted to reflect survival within the strata of minimal patient-level risk within each group.20 The lowest-risk group from these analyses, stratified by rupture status and repair type, was used to demonstrate these adjusted results with Kaplan Meier plots.21,22 In patients undergoing repair for rupture, the survival curves by repair type crossed one another; therefore, the assumption of proportional hazards was not satisfied, precluding calculation of a adjusted hazard ratio for endovascular repair in ruptured patients. Accordingly, for ruptured patients, we stratified our Cox models by repair type and calculated hazard ratios for the remaining covariates, as reported in Table II in the online-only Data Supplement.
Second, we used propensity-matching methods to create similar cohorts for survival analysis.23 First, we generated a propensity score for the likelihood of undergoing TEVAR based on a multivariable logistic model that described the association between preoperative patient characteristics and the choice to perform TEVAR. Because the range of propensity score was broad, we used a stratified propensity analysis.24,25 In other words, adequate propensity matches were limited to the lowest-risk quartile of propensity score because higher-risk patients undergoing TEVAR were not able to be adequately matched within the open surgical cohort. Within a sample of patients between 65 and 75 years of age who underwent surgery during the last 4 years of our study period, we propensity matched patients by age and comorbidity. This allowed us to generate 2 cohorts that were matched in terms of age, sex, race, era of procedure, comorbidities that constitute the Charlson score, and Charlson score itself. (Table 2). We used χ2 tests and t tests to ensure that there were no significant differences in preoperative characteristics between the open repair and TEVAR cohorts. We randomly selected 550 patients each from these 2 matched cohorts, and we compared 4-year survival between these groups using Kaplan-Meier analysis. Given the small sample size in the TEVAR rupture cohort, only intact TAAs were studied in this portion of the analysis.
Further details of the models used in the adjusted survival analysis and propensity-matched analysis are available in Table II in the online-only Data Supplement. All analyses were performed with SAS (SAS Institute, Cary, NC) and STATA 10 (STATA, College Station, TX).
Characteristics of the Cohort of Patients Undergoing TAA Repair
Overall, we studied 12 573 Medicare patients who underwent open procedures and 2732 patients who underwent TEVAR (Figure 1). By presentation status, 13 998 patients presented for surgery with intact TAA (11 565 open repair, 2433 TEVAR), whereas 1307 patients underwent surgery for ruptured TAA (1008 open repair, 299 TEVAR). Patient characteristics in the cohort are shown in Table 2.
Several demographic differences existed between open repair and TEVAR patients with intact TAA. First, patients undergoing TEVAR were significantly older than patients undergoing open repair (75.9 years versus 73.8 years; P<0.0001). Second, the proportion of male patients was slightly higher among patients undergoing TEVAR than open repair (58.7% versus 55.4%; P<0.0001). Other differences were also apparent across the open repair and TEVAR cohorts, including higher rates of diabetes mellitus, myocardial infarction, chronic obstructive pulmonary disease, and chronic renal failure and a higher proportion of black patients (7.5% TEVAR, 3.8% open; P=0.001).
Differences also existed between patients presenting with intact and ruptured TAA. First, patients with ruptured TAA were older on average than patients with intact TAA by >2 years (76.4 versus 74.1 years; P=0.0001). Second, the proportion of black patients was significantly higher in the ruptured cohort compared with the intact cohort (7.3% versus 4.4%; P=0.0001). Third, the incidence of comorbidities such as diabetes mellitus, cerebrovascular disease, chronic obstructive pulmonary disease, and renal failure was slightly higher in patients undergoing repair for rupture compared with patients presenting for elective repair.
Finally, within the group of patients undergoing repair for ruptured TAA, patients undergoing TEVAR were significantly older than patients undergoing open repair (77.9 versus 76.4 years; P=0.001). Furthermore, patients selected for TEVAR for ruptured TAA had a higher incidence of diabetes mellitus, chronic obstructive pulmonary disease, black race, renal failure, and malignancy than patients selected for open repair.
As shown in Figure 2, the lowest perioperative mortality rate occurred in patients undergoing repair of intact TAA with TEVAR (6.1%; 95% CI, 5.1–7.0). Although the perioperative mortality rate for open repair was slightly higher (7.1%; 95% CI, 6.7–7.6), the clinical magnitude of this difference was small and borderline in terms of statistical significance (P=0.07). Among patients presenting with ruptured thoracic aneurysms, perioperative mortality was 28.4% (95% CI, 23.2–33.5) for TEVAR and 45.6% (95% CI, 42.5–48.7) for open repair (P=0.0001).
Five-Year Survival by Repair Type (Unadjusted and Adjusted)
Unadjusted long-term survival varied by presentation (intact versus ruptured) and repair type (open repair versus TEVAR; Figure 3A). Even though patients with intact TAA selected for TEVAR had lower perioperative mortality, patients selected for open repair reclaimed the survival advantage within the first year after surgery (1-year survival by life-table analysis: 87% open repair [95% CI, 86–88], 82% TEVAR [95% CI, 80–83]; log-rank P=0.001). This survival advantage continued to accumulate over time, as seen in our 5-year survival data (5-year survival by life-table analysis: 72% [95% CI, 71–73] open repair, 62% TEVAR [95% CI, 60–65; ] log-rank P=0.001). As shown in Figure 3A, the steeper slope in the survival curve for TEVAR patients undergoing repair of intact TAA demonstrates the poorer long-term survival in patients selected for TEVAR compared with those selected for open repair.
Similarly, patients with ruptured TAA repaired with TEVAR had significantly better short-term survival. However, similar to intact repair, this survival advantage disappeared by 1.5 years postoperatively. Thereafter, survival rates remained similar between repair type. After 5 years, by life-table analysis, <30% of patients were alive after repair of their ruptured TAA regardless of the type of repair (26% [95% CI, 23–30] open repair, 23% [95% CI, 16–32] TEVAR; log-rank P=0.37).
In survival analyses adjusted for age, sex, race, era of procedure, and Charlson comorbidity score, our results were similar to our unadjusted analyses. In patients with intact TAA, the perioperative survival advantage incurred by TEVAR disappeared within the first year, and 5-year survival was significantly worse in patients undergoing TEVAR (89% versus 79%; log-rank P<0.0001; Figure 3B). In patients with ruptured TAA, the survival advantage incurred by TEVAR disappeared within the first 90 days after surgery, and 5-year survival was significantly worse in patients undergoing TEVAR compared with open repair (62% versus 45%; log-rank P=0.0001).
Survival in Propensity-Matched Cohorts
In this analysis, we compared patients who were propensity matched (within the lowest-risk quartile of propensity score) by age, sex, race, year of repair, and comorbidity score, thereby generating 2 distinct cohorts of patients. These cohorts of patients were similar in terms of patient characteristics available for measurement in administrative claims, as shown in Table 2, and underwent either open repair or TEVAR. Within these propensity-matched open repair and TEVAR cohorts, there were no significant statistical differences in patient characteristics.
In the propensity-matched cohorts, perioperative mortality was statistically similar in patients undergoing TEVAR compared with open repair (4.5% [95% CI, 2.8–6.2] open repair versus 4.2% [95% CI, 2.5–5.8] TEVAR; P=0.78). Any difference in perioperative mortality incurred by TEVAR disappeared within the first year postoperatively, and late survival was significantly worse in patients undergoing TEVAR (Figure 3C). By life-table analysis at 5 years postoperatively, late survival was significantly worse in patients undergoing TEVAR (73%; 95% CI, 68–76) than open repair (81%; 95% CI, 77–85) within the propensity-matched cohort (log rank P=0.007).
Outcomes Before and After FDA Approval
Finally, to examine any effect of change in practice pattern after the FDA approval of commercial devices specifically designed for TEVAR, we examined in-hospital/30-day mortality and 3-year survival before and after FDA approval of a commercial device designed specifically for TEVAR in 2005. Before FDA approval in 2005, 631 patients underwent TEVAR of intact TAA, and their 30-day/in-hospital mortality was 7.1%. After FDA approval, the number of patients in our cohort undergoing TEVAR was much larger (n=1802) and represented a larger proportion of all patients undergoing TAA repair (TEVAR=8.5% of all TAA before FDA approval, TEVAR=27.2% of all TAA after FDA approval; P<0.0001). Patient characteristics of those undergoing TEVAR were largely similar before and after FDA approval (Table 3), except that patients undergoing TEVAR after FDA approval were slightly older. Although perioperative mortality after TEVAR was lower after FDA approval (5.8%), this difference was not significantly lower than the perioperative mortality before FDA approval. Likewise, 3-year survival was similar after TEVAR before and after FDA approval (Table 4).
However, for patients undergoing open repair, patient characteristics, perioperative mortality, and 3-year survival were all significantly different before and after FDA approval. After FDA approval, patients selected for open repair were less likely to have a history of heart disease, cerebrovascular disease, or chronic obstructive pulmonary disease. Patients selected for open repair after FDA approval also had a lower average Charlson comorbidity score. Finally, perioperative mortality decreased from 8.4% to 5.4% (P=0.0001) after FDA approval, and 3-year survival was higher in patients undergoing open repair after FDA approval (Table 4).
Although the competing mortalities of observation and open surgical repair for TAA have been investigated for several decades, the effect of TEVAR on survival remains less well studied. Most reports on survival after TEVAR are single-center series or the results of highly selected, industry-sponsored registries.4,6,26–29 Our study examined survival after open repair and TEVAR in national, real-world practice and found that although perioperative mortality is lower in TEVAR, patients selected for TEVAR have worse long-term survival than patients selected for open repair. These results suggest that higher-risk patients are being offered TEVAR and that some do not benefit in terms of long-term survival.
The effect of a less invasive endovascular option for aneurysm repair on patient selection and survival after aortic aneurysm surgery has been a topic of extensive study but primarily in patients with infrarenal abdominal aortic aneurysm (AAA).3,30 Several randomized trials31–33 have demonstrated lower perioperative mortality with endovascular techniques. However, in these trials and large observational analyses,30 the survival advantage gained by an endovascular approach consistently disappears within 2 years after surgery, and little difference in long-term survival is evident thereafter across procedures. Patients who experience late death after infrarenal AAA repair most commonly die of cardiopulmonary comorbidities unrelated to their aneurysm; relatively few experience aneurysm-related death in either open or endovascular repair.34 In other words, in both randomized trials and real-world practice, although endovascular repair is as effective in preventing aneurysm-related death as open repair, it does not result in prolonged improvement or detriment in survival. Rather, it has decreased perioperative morbidity and mortality and has expanded the pool of patients undergoing elective repair.35
Our results demonstrate that the treatment of TAA follows a course similar to infrarenal AAA with 1 important exception. As with infrarenal AAA, we found a survival advantage in short-term mortality for patients who undergo TEVAR compared with open repair, especially in patients presenting with ruptured TAA; this finding has been reported in similar analyses in other national data sets.36 Furthermore, as with infrarenal AAA, any survival advantage gained in the perioperative period after endovascular repair was lost within 2 years after surgery. However, unlike infrarenal AAA, wherein long-term survival is similar across procedure type, adjusted survival at 5 years was significantly worse for patients selected for TEVAR compared with open repair. Therefore, the widespread application of TEVAR has resulted in a cohort of patients who previously may not have undergone surgery but now are undergoing TEVAR. Patients selected for TEVAR have worse survival than patients undergoing open repair, and many of these deaths occur within the first 2 years after TEVAR. These deaths could be due to the selection of “sicker” patients for TEVAR, although our finding of poorer survival after TEVAR persists even in propensity-matched analyses that account for differences in patient risk measurable using administrative claims. Alternatively, these differences in survival could be explained by device-related complications occurring within the first 5 years after surgery.
As with patients with infrarenal AAA, we suspect that the loss of survival advantage is secondary to patient-level comorbidities. For example, in the EVAR-2 trial,37 survival was similar among patients treated with endovascular repair and patients who did not undergo repair. All patients in EVAR-2 were deemed unacceptable for open repair because they often had comorbidities that limited their survival but not their ability to undergo endovascular repair. The data available from our study support this presumption; TEVAR patients tend to be older and to have higher comorbidity scores than the patients selected for open repair. However, it is important to acknowledge that our findings are based solely on administrative claims; therefore, our analysis is limited in terms of clinical detail.
Given the lack of anatomic and procedural detail in our data set, it remains uncertain whether the lack of survival advantage seen in patients selected for TEVAR could be related to late-occurring, device-related complications. To best determine whether late device-related complications are contributing to the poorer “real-world” survival in patients undergoing TEVAR, postimplantation follow-up with device-specific registries is necessary. Efforts in this regard have already been discussed and implemented by specialty societies interested in the outcomes of endovascular procedures; these registries will also provide more robust clinical detail for risk adjustment compared with the administrative data used in our present work.38
Finally, after FDA approval and widespread implementation of TEVAR, the perioperative mortality associated with open repair declined significantly, and a small but significant survival benefit was evident 3 years after surgery. Although indirect, this evidence suggests that after FDA approval, higher-risk patients were being offered TEVAR rather than open repair, and patients selected for open repair were lower risk than those selected for TEVAR. However, more definitive characterization of these changes is necessary and requires registry-based data with more detailed covariates for risk adjustment than currently available from administrative data.
Our findings add important context to the studies used to demonstrate the efficacy of endovascular repair of TAA.12,13,39–41 First, compared with data from TEVAR clinical trials (Table 5), it is evident that perioperative mortality is higher in real-world practice than in the centers of excellence where the clinical trials were performed. Second, when examining the relative effectiveness of TEVAR compared with open surgical repair at 5 years, we see that it is important where the bar is set in terms of open surgical repair. In real-world practice, patients selected for open repair had better survival than the surgical control subjects used in clinical trials (72% 5-year survival in Medicare, 67% 5-year survival in the single trial that reported this measure). Furthermore, patients selected for TEVAR in real-world practice performed slightly worse than patients studied in the clinical trial (62% 5-year survival in Medicare versus 68% 5-year survival in the clinical trial). Collectively, these 2 differences resulted in the disparity in conclusions between our study, in which TEVAR patients fared significantly worse at 5 years, and the clinical trial, in which outcomes were similar at 5 years. Which rate is right? Certainly, future trials and analyses will address this question. Although a formal meta-analysis comparing these results is beyond the scope of this article, a recent meta-analysis addressed this question and included the clinical trials shown in Table 5, as well as several single-center studies reporting 2- and 3-year outcomes. These investigators found little long-term survival benefit for patients undergoing TEVAR compared with open surgical repair.42 Therefore, given the findings in our study and others, there is little evidence to suggest that long-term survival is better in patients selected for TEVAR compared with open surgical repair. Furthermore, depending on the surgical control subjects selected for comparison, survival after TEVAR may be worse.13,39–41
Our study has several limitations. First, as mentioned previously, the limitations of administrative data in describing clinical details of aortic aneurysm repair and providing clinical-level covariates for risk adjustment have been well described.43 Therefore, because we sought to be highly specific in our attempt to create a cohort of descending thoracic aneurysms, we searched for both procedural and diagnostic codes commonly used for branched, fenestrated, ascending, and transverse arch thoracic aortic repair and eliminated these patients from our cohort of isolated descending TAA to ensure uniformity in our cohort. Second, our comparison of patients undergoing open repair and TEVAR procedures is risk adjusted with the use of demographic data, ICD-9–derived diagnoses, and a propensity-matched model studying low-risk patients undergoing TEVAR and open surgical repair. Further attempts to develop comparative populations, either via instrumental variable analysis44 or other statistical techniques designed to account for selection bias in observational studies, would be limited by the absence of important clinical variables such as aneurysm extent, size, and prior aneurysm surgery. Third, FDA approval was granted in 2005, and our data set extends to 2007, limiting our insight into patients who underwent surgery in the post-FDA approval era. However, because patients with TAA experience limited survival regardless of procedure type, the overall size of our cohort, combined with the frequency of these events, provided insight into significant survival differences even in this limited time period. And finally, our data set does not allow us to discern causes of death.34 It is possible that differences in aneurysm-related deaths might better inform decisions concerning which patients should undergo open repair or TEVAR, but these data would be unlikely to alter the primary conclusion of our study.
Our study demonstrates that short- and long-term survival after surgery for TAA varies by presentation and repair type. The consistent short-term survival advantage offered by TEVAR disappears within the first 2 years after surgery, and patients currently selected for TEVAR have worse long-term survival than patients selected for open repair. These results suggest that higher-risk patients are being offered TEVAR and that some do not benefit on the basis of long-term survival. Future work is needed to identify TEVAR candidates unlikely to benefit from repair.
Sources of Funding
Drs Goodney and Stone received a grant from the Hitchcock Foundation at Dartmouth Medical School to fund the research described here. Dr Goodney received a Career Development Award from the National Heart, Lung, and Blood Institute (1K08HL05676–01). Dr Goodney was supported by a Lifeline Research Award from the Society for Vascular Surgery Foundation.
Dr Fillinger received research and grant support and consultative fees from W.L. Gore, Cook Medical, and Medtronic, although none of this funding supported the research described here. The other authors report no conflicts.
Continuing medical education (CME) credit is available for this article. Go to http://cme.ahajournals.org to take the quiz.
The online-only Data Supplement is available with this article at http://circ.ahajournals.org/lookup/suppl/doi:10.1161/CIRCULATIONAHA.111.033944/-/DC1.
- Received March 23, 2011.
- Accepted September 22, 2011.
- © 2011 American Heart Association, Inc.
Current Procedural Technology Manual. Chicago, IL: American Medical Association; 2010.
- Iezzoni LI
Food and Drug Administration. Recently approved devices: Gore TAG thoracic endoprosthesis. www.fda.gov. Accessed March 23, 2005.
- Hosmer DW,
- Lemeshow S,
- May S
- Vittinghoff E,
- Glidden DV,
- Shoboski SC,
- McCulloch CE
- Rosenbaum PR,
- Rubin. DB
- Becker SO,
- Ichino A
- Crawford ES,
- Svensson LG,
- Coselli JS,
- Safi HJ,
- Hess KR
- Ryan M,
- Valazquez O,
- Martinez E,
- Patel S,
- Parodi J,
- Karmacharya J
Society for Vascular Surgery. Vascular quality initiative quality improvement database. www.Vascularweb.Org. 2010. Accessed April 1, 2011.
- Fattori R,
- Nienaber CA,
- Rousseau H,
- Beregi JP,
- Heijmen R,
- Grabenwoger M,
- Piquet P,
- Lovato L,
- Dabbech C,
- Kische S,
- Gaxotte V,
- Schepens M,
- Ehrlich M,
- Bartoli JM
- Cheng D,
- Martin J,
- Shennib H,
- Dunning J,
- Muneretto C,
- Schueler S,
- Von Segesser L,
- Sergeant P,
- Turina M
Using Medicare claims from 1998 to 2007, we examined short and long-term survival of patients with descending thoracic aortic aneurysms (TAA) following open surgical repair and endovascular repair (TEVAR). Overall, we studied 12 573 patients who underwent open repair, and 2732 patients who underwent TEVAR. Perioperative mortality was lower in patients undergoing TEVAR compared with open repair for both intact (6.1% versus 7.1%, P=0.07) and ruptured TAA (28% versus 46%, P=0.0001). However, patients with intact TAA selected for TEVAR had significantly worse survival than open patients at one year (87% open, 82% TEVAR, P=0.001) and five years (72% open, 62% TEVAR, P= 0.001), and analyses adjusting for patient-level comorbidities produced similar results. Therefore, although perioperative mortality is lower with TEVAR, patients selected for TEVAR have worse long-term survival than patients selected for open repair in our observational analysis of Medicare patients. Future work is needed to determine if these deaths are due to the selection of high-risk patients for TEVAR, or due to late device-related complications from the TEVAR itself.