Early Financial Outcomes of Physician Modified Endograft Programs Are Dictated by Device Cost.

INTRODUCTION: Physician-modified endografts (PMEGs) have been used for repair of thoracoabdominal aortic aneurysms (TAAAs) for 2 decades with good outcomes but limited financial data. This study compared the financial and clinical outcomes of PMEGs to the Cook Zenith-Fenestrated (ZFEN) graft and open surgical repair (OSR). METHODS: A retrospective review of financial and clinical data was performed for all patients who underwent endovascular or OSR of juxtarenal aortic aneurysms and TAAAs from January 2018 to December 2022 at an academic medical center. Clinical presentation, demographics, operative details, and outcomes were reviewed. Financial data was obtained through the institution's finance department. The primary end point was contribution margin (CM). RESULTS: Thirty patients met inclusion criteria, consisting of twelve PMEG, seven ZFEN, and eleven open repairs. PMEG repairs had a total CM of -$110,000 compared to $18,000 for ZFEN and $290,000 for OSR. Aortic and branch artery implants were major cost-drivers for endovascular procedures. Extent II TAAA repairs were the costliest PMEG procedure, with a total device cost of $59,000 per case. PMEG repairs had 30-d and 1-y mortality rates of 8.3% which was not significantly different from ZFEN (0.0%, P = 0.46; 0.0%, P = 0.46) or OSR (9.1%, P = 0.95; 18%, P = 0.51). Average intensive care unit and hospital stay after PMEG repairs were comparable to ZFEN and shorter than OSR. CONCLUSIONS: Our study suggests that PMEG repairs yield a negative CM. To make these cases financially viable for hospital systems, device costs will need to be reduced or reimbursement rates increased by approximately $8800.

Hospitalization Cost and In-hospital Outcomes Following Type B Thoracic Aortic Dissection Repair.

BACKGROUND: Several studies have reported lower mortality and morbidity after thoracic endovascular aortic repair (TEVAR) when compared to open surgical repair (OSR) in the treatment of type B aortic dissection (TbAD). However, there are few studies in the literature on the cost of both treatment options. Thus, the aim of this study is to focus on in-hospital outcomes and cost associated with TbAD repair procedures in a national database in the United States. METHODS: A retrospective review of the Premier Healthcare Database (PHD) between June 2009 and March 2015 was performed. ICD-9-CM codes were used to identify patients who underwent OSR or TEVAR for TbAD. Endpoints included in-hospital adverse events, in-hospital mortality and hospitalization cost. Logistic regression models and generalized linear models were used to assess the impact of treatment type on the main outcomes. RESULTS: Out of 1752 patients with TbAD, 54.3% underwent OSR and 45.7% underwent TEVAR. Patients in the TEVAR group were older [median age, 64 (IQR 54-73) vs. 59 (IQR 49-70), P < 1] and more likely to have preexisting comorbidities. IAE rates were 78.6% for the OSR group compared to 43.1% for the TEVAR group, P < 0.001. Patients in the OSR group showed significantly higher in-hospital mortality (15.3% vs. 5.9%, P < 0.001). After adjusting for potential confounders, OSR was associated with a 5-fold increase in IAE [aOR(95%CI): 4.8 (3.8-6.1), P < 0.001] and a 3-fold increase in in-hospital mortality [aOR(95%CI): 3.3 (2.1-5.1), P < 0.001]. In regards to charges related to the hospital stay, total cost was significantly higher among patients undergoing OSR $53,371 ($39,029-$80,471) vs. TEVAR $45,311 ($31,479-$67,960), P < 0.001. CONCLUSION: The present study shows that TEVAR presents an advantage in terms of morbidity, mortality and cost when compared to OSR in the treatment of TbAD. However, long-term cost-effectiveness of both procedures remains unknown. Further research is warranted to see whether the superiority of TEVAR is maintained over time.

Health care costs of endovascular compared with open thoracoabdominal aortic aneurysm repair.

OBJECTIVE: To compare 1-year health care costs between endovascular and open thoracoabdominal aortic aneurysm (TAAA). METHODS: Population-based administrative health databases were used to capture TAAA repairs performed in Ontario, Canada, between January 2006 and February 2017. All health care costs incurred by the Ministry of Health from a single-payer universal health care system were included. Costs of the aortic endografts and ancillary devices for the index procedure were estimated as C$44,000 per endovascular case vs C$1000 for open cases, based on previous reports. Costs (2017 Canadian dollars) were calculated in phases (1, 1-3, 3-6, and 6-12 months from surgery) with censoring for death. For each phase, propensity score matching of endovascular and open cases based on preoperative patient and hospital characteristics was used. The association between preoperative characteristics (including repair approach) and the first month postprocedure cost was characterized through multivariable analysis. RESULTS: Overall 664 TAAA repairs were identified (open, n = 361 [54.5%] and endovascular, n = 303 [45.6%]). At 1 month, the median cost was higher for endovascular TAAA repair in the prematching cohort (C$64,892 vs C$36,647; P < .01). Similarly, in 241 well-balanced endovascular/open patient pairs after propensity score matching, the median health care costs were higher in endovascular TAAA cases during the first month (C$62,802 vs C$33,605; P < .01). The 1- to 3-month median cost was not statistically different between endovascular and open TAAA cases either before matching (C$2781 vs C$2618; P = .71) or after matching (C$2762 vs C$2092; P = .58). Likewise, in the 3- to 6-month and 6- to 12-month postprocedure intervals, there were no significant differences in the median health care costs between groups. On multivariable analysis, older age (5-year increments) (relative change [RC] in mean cost, 1.05; 95% confidence interval [CI], 1.04-1.06; P = .01), urgent procedures (RC, 1.29; 95% CI, 1.10-1.52; P < .01), and history of stroke (RC, 1.34; 95% CI, 1.00-1.78; P = .05) were associated with higher costs in the first postoperative month, whereas open relative to endovascular TAAA repair was associated with a decreased 1-month cost (RC, 0.65; 95% CI, 0.56-0.74; P < .01). CONCLUSIONS: TAAA repair is expensive regardless of technique. Compared with open TAAA repair, endovascular repair was associated with a higher early cost, owing to the upfront cost of the endograft and aortic ancillary devices. There was no difference in cost from 1 to 12 months after repair. A decrease in the cost of endovascular devices might allow equivalent costs between endovascular and open TAAA repair.

Ten-Year Clinical Characteristics and Early Outcomes of Type B Aortic Dissection Patients With Thoracic Endovascular Aortic Repair.

OBJECTIVE/BACKGROUND: This study examined the 10-year hospitalization characteristics, economic patterns and early clinical outcomes of type B aortic dissection (TBAD) patients that underwent thoracic endovascular aortic repair (TEVAR) in one high-volume hospital in China. METHODS: We performed a population-based retrospective analysis based on electronic medical record system data provided by Zhongshan Hospital Fudan University from 2009 to 2018. RESULTS: We identified 1,367 cases of TBAD patients with TEVAR over the past decade. The total incidence of in-hospital complications was 7.6% (104 of 1,367), among which acute kidney injury (AKI) had the highest incidence (3.1%, 42 of 1,367). Aortic-related reintervention was performed in 7 patients (0.5%). The overall aortic-related in-hospital mortality rate was 2.7% (37 of 1,367) and had no significant time-varying trend (P = 0.2). Among these, 27% of in-hospital deaths were caused by retrograde type A dissection (RTAD). Chronic TBAD had a higher risk of in-hospital death versus acute TBAD, with a risk ratio of 2.69 (95% confidence interval [CI]: 1.19-6.09). Patients with hypertension (risk ratio 4.63, 95% CI: 1.38, 15.54) also had a higher in-hospital death risk. These 2 factors were also the predictive factors for the composite endpoint of in-hospital adverse events (risk ratio 2.17, 95% CI: 1.43, 3.29 and risk ratio 4.83, 95% CI: 1.90, 12.28, respectively), in addition to Marfan syndrome (risk ratio 4.05, 95% CI: 1.61, 10.19). The average length of hospitalization significantly declined during the past decade (annual percentage change -6.3%, 95% CI -8.2 to -4.3), and the stent-grafts (SGs) cost was the main expenditure of the total hospitalization costs. CONCLUSION: Our study showed a favorable early outcome of TEVAR over the past decade. Greater attention should be paid to certain risk factors in order to reduce the in-hospital adverse events. SG expenditure is still the primary economic burden on Chinese TBAD patients.

Economic Burden and Healthcare Resource Use for Thoracic Aortic Dissections and Thoracic Aortic Aneurysms-A Population-Based Cost-of-Illness Analysis.

Background Thoracic aortic dissections (TADs) and thoracic aortic aneurysms (TAAs) are resource intensive. We sought to determine economic burden and healthcare resource use to guide health policy. Methods and Results Using universal healthcare coverage data for Ontario, Canada, from 2003 to 2016, a cost-of-illness analysis was performed. From a single-payer's perspective, direct costs (hospitalization, reinterventions, readmissions, rehabilitation, extended care, home care, prescription drugs, and imaging) were assessed in 2017 Canadian dollars. Controls without TADs or TAAs were matched 10:1 on age, sex, and socioeconomic status to cases with TADs or TAAs to compare posthospital service use to the general population. Linear and spline regression were used for cost trends. Total hospital costs increased from $9 M to $20.7 M for TADs (P<0.0001) and $13 M to $18 M for TAAs (P<0.001). Costs cumulated to $587 M for 17 113 cases. Median hospital costs for TADs were $11 525 ($6102 medical, $26 896 endograft, and $30 372 surgery) with an increase over time (P=0.04). For TAAs, median costs were $16 683 ($7247 medical, $11 679 endograft, and $22 949 surgery) with a decrease over time (P=0.03). Home care was the most used posthospital service (TADs 44%, TAAs 38%), but rehabilitation had the highest median cost (TADs $11.9 M, TAAs $11 M). Men had increased median costs for indexed hospitalizations relative to women, yet women used more posthospital services with higher service costs. Conclusions Total yearly costs have increased for TADs and TAAs. Median hospital costs have increased for TADs yet decreased for TAAs. Women use posthospital healthcare services more often than men.

Clinical and economic outcomes of ProGlide compared with surgical repair of large bore arterial access.

Aim: This study compared real-world complication rates, hospitalization duration and costs, among patients undergoing arterial repair using the Perclose ProGlide (ProGlide) versus surgical cutdown (Cutdown). Materials & methods: Retrospective study of matched patients who underwent transcatheter aortic valve replacement/repair, endovascular abdominal aortic aneurysm repair, thoracic endovascular aortic repair or balloon aortic valvuloplasty with arterial repair by either ProGlide or Cutdown between 1 January 2013 and 24 April 2017. Results: Infections and blood transfusions were lower in the ProGlide cohort. Patients in the ProGlide cohort had a 42.5% shorter index hospitalization, which corresponded to US$14,687 lower costs. Conclusion: The use of ProGlide for arterial repair was associated with significantly lower transfusion rates, shorter index hospitalization and lower hospitalization costs compared with surgical cutdown.

A Decade of Thoracic Endovascular Aortic Aneurysm Repair in New York State: Volumes, Outcomes, and Implications for the Dissemination of Endovascular Technology.

BACKGROUND: The purpose of this study was to characterize utilization and outcomes of thoracic endovascular aortic aneurysm repair (TEVAR) in New York State during the first decade of commercial availability, with respect to evolving indications, results, and costs. Of specific interest was evaluation of the volume-outcome relationship for this relatively uncommon procedure. METHODS: The New York Statewide Planning and Research Cooperative System database was queried to identify patients undergoing TEVAR from 2005 to 2014 for aortic dissection (AD), non-ruptured aneurysm (NRA), and ruptured aneurysm (RA). Outcomes assessed included in-hospital mortality, complications, and costs. Linkage to the National Provider Identifier and New York Office of Professions databases facilitated comparisons by surgeon and facility volume. RESULTS: One thousand eight hundred thirty-eight patients were identified: 334 AD, 226 RA, and 1,278 NRA. Since introduction, TEVAR implantation increased significantly over the 10-year period in all groups (P < 0.01), with recent increase in utilization for AD. Increased in-hospital mortality correlated with RA (OR 5.52 [3.02-10.08], P < 0.01), coagulopathy (3.38 [2.02-5.66], P < 0.01), cerebrovascular disease (2.47 [1.17-5.22], P = 0.02), and nonwhite/nonblack race (1.74 [1.08-2.82], P = 0.02). Early in the experience (2005-2007), patients were more likely to be treated at high-volume facilities (>17 per year) and by high-volume surgeons (>5 per year), (P < 0.01). Since 2011, however, most patients (53%) have undergone TEVAR by low-volume surgeons (<3 per year). Neither surgeon nor hospital volume was associated with clinical outcomes. CONCLUSIONS: Since the introduction of TEVAR, comparable results have been obtained across hospital and surgeon volume strata. Favorable outcomes, even in low-volume settings, underscore the complexity of volume-outcome relationships in high-acuity procedures. These findings have implications for credentialing, regionalization, and future dissemination of advanced endovascular technology.

Clinical results and medical costs of thoracic endovascular aortic repair in patients over 80 years of age.

Thoracic endovascular aortic repair (TEVAR) is expected to be minimally invasive, especially in older patients. However, clinical results of TEVAR in octogenarians including medical costs are limited. Between 2010 and 2016, a total of 57 patients over 80 years of age (mean age 84.1 ± 3.4 years) underwent TEVAR at our hospital. The proximal landing zone (PLZ) was zone 0 in 7 patients (12.3%), zone 1 in 10 patients (17.5%), zone 2 in 9 patients (15.8%), zone 3 in 13 patients (22.8%), and zone 4 in 18 patients (31.6%). The mean follow-up time was 23 ± 19 months (range 1-71 months). The follow-up rate was 96.5%. The hospital mortality rate was 1.8%. Stroke occurred in three patients (zone 0: 2, zone 3: 1, 5.3%). The mean hospital stay was 21.8 ± 21.4 days (range 5-98 days), and the rate of being discharged home was 84.2%. The 1-year and 3-year survival rates were 76.1% and 55.1% and the 1-year and 3-year re-intervention-free rates of the thoracic aorta were 97.6% and 94.5%, respectively. The mean total cost by the time of hospital discharge was ¥5,360,000 ± 2,360,000. The clinical results of TEVAR in patients over 80 years of age are acceptable with early postoperative recovery, low mortality and morbidity, and midterm durability.

Outcomes and cost of open versus endovascular repair of intact thoracoabdominal aortic aneurysm.

OBJECTIVE: Many previous studies have evaluated the outcomes of open and endovascular repair of thoracoabdominal aortic aneurysms (TAAAs). However, little is known about the differences in cost of these procedures and the potential factors driving these differences. The aim of this study was to evaluate the outcomes and cost of open aortic repair (OAR) vs endovascular repair of intact TAAA. METHODS: All patients undergoing repair for intact TAAA were identified in the Premier Healthcare Database (July 2009-March 2015). Categorical and continuous variables were analyzed using the χ2 test, Student t-test, and median test as appropriate. A multivariable generalized linear model was used to examine total in-hospital cost. RESULTS: A total of 879 TAAA repairs were identified (481 [55%) endovascular repairs vs 398 [45%] OARs). Patients undergoing endovascular repair were on average 5 years older (71.2 [±10.0] years vs 66.5 [±10.9] years; P < .001) and more likely to be female (48% vs 42%; P = .05) and hypertensive (87% vs 80%; P = .009). Otherwise, there were no significant differences in comorbidities between the two groups. Patients undergoing OAR were more likely to stay longer in the hospital (median [interquartile range], 11 [7-20] days vs 5 [2-9] days; P < .001). In-hospital mortality (15% vs 5%; P < .001) and all major complications were two to three times higher after OAR. The median total cost of OAR was significantly higher compared with endovascular repair (cost [interquartile range], $44,355 [$32,177-$54,824] vs $36,612 [$24,395-$53,554]; P = .004). The majority of the cost attributed to TAAA repair was also higher in patients undergoing open repair: room and board ($11,561 vs $4720), operating room ($9230 vs $4929), pharmacy ($2309 vs $900), blood bank ($1189 vs $195), rehabilitation/physical therapy ($378 vs $236), and respiratory therapy ($875 vs $168; all P < .001). Only the cost of central supplies, which includes endovascular grafts and stents, was the highest among patients undergoing endovascular repair ($17,472 vs $5501; P < .001). The cost of diagnostic imaging ($625 vs $595) and anesthesia ($479 vs $478) was similar in both approaches. In a multivariable analysis, the adjusted total hospitalization cost for OAR was $5974 (95% confidence interval, $1828-$10,120; P = .005) higher compared with endovascular repair. However, after adjusting for in-hospital complications, no difference was seen between the two approaches (-$460; 95% confidence interval, -$4390 to $3470; P = .82). CONCLUSIONS: In this large cohort of intact TAAAs, we showed a significantly higher adjusted total hospitalization cost of open compared with endovascular repair despite the additional cost of endografts. This is likely driven by longer length of stay and higher morbidity after OAR.

Use of extracorporeal bypass is associated with improved outcomes in open thoracic and thoracoabdominal aortic aneurysm repair.

OBJECTIVE: There is no consensus on the use or benefit of extracorporeal circulation (EC) during aneurysm repair of the descending thoracic aorta (DTA) or thoracoabdominal aorta (TAA). We evaluated the role of EC during DTA or TAA aneurysm repair using U.S. Medicare data. METHODS: Medicare (2004-2007) patients undergoing open repair of nonruptured DTA or TAA aneurysm were identified by International Classification of Diseases, Ninth Revision code. Specific exclusions included ascending aortic or arch repairs, concomitant cardiac procedures, and procedures employing deep hypothermic circulatory arrest. The impact of EC (code 3961) on early and late outcomes was analyzed using univariate analysis and multivariable regression. Survival was assessed using Kaplan-Meier analysis and Cox proportional hazards regression models. RESULTS: There were 4230 patients who had repair of intact DTA or TAA aneurysms, 2433 (57%) of which employed EC. Differences in baseline clinical features of EC and non-EC patients showed that patients undergoing aortic reconstruction with EC were older (73 ± 1 years vs 72 ± 1 years; P = .002), were more likely to be female (53% vs 47%; P < .001), and had more hypertension (56% vs 53%; P = .02); they had less chronic obstructive pulmonary disease (28% vs 34%; P < .0001), peripheral vascular disease (5.7% vs 11.3%; P < .001), and chronic kidney disease (7.7% vs 5.5%; P = .003). The 30-day mortality (9.7% for EC vs 12.2%; P = .02) and any major complication (49% for EC vs 58%; P < .001) were significantly reduced with EC use. EC use was associated with a shorter length of stay (13.5 ± 13 days vs 17.2 ± 18 days; P < .01) and lower total hospital charges ($151,000 ± 140,000 vs $180,000 ± 190,000; P < .01) compared with non-EC patients. EC patients were more likely to be discharged home instead of to an extended care facility (67% vs 56%; P < .01). Multivariable regression modeling to adjust for baseline clinical differences showed EC to independently reduce the risk of operative mortality (odds ratio [OR], 0.80; 95% confidence interval [CI], 0.65-0.97; P = .02), any complication (OR, 0.67; 95% CI, 0.59-0.76; P < .01), pulmonary complications (OR, 0.68; 95% CI, 0.59-0.79; P < .01), and acute renal failure (OR, 0.52; 95% CI, 0.44-0.61; P < .01). Long-term survival was higher (log-rank, P < .01) in EC patients at 1 year (81% ± 0.8% vs 73% ± 1%) and 5 years (67% ± 1% vs 52% ± 1%). Risk-adjusted Cox proportional hazards regression also showed that EC was independently associated with improved long-term survival (hazard ratio, 0.69; 95% CI, 0.63-0.74; P < .01). CONCLUSIONS: Although important clinical variables such as DTA or TAA aneurysm extent and spinal cord ischemic complications cannot be assessed with the Medicare database, EC use during open DTA and TAA aneurysm repair is associated with improved late survival and a significant reduction in operative mortality, morbidity, and procedural costs. These data indicate that EC should be a more widely applied adjunct in open DTA or TAA aneurysm repair.

Unplanned stents in thoracic endovascular aortic repair for type B aortic dissection: A 16-year single-center report.

Background Unplanned stents in thoracic endovascular aortic repair mean additional stents implantation beyond the preoperative planning to achieve operation success. This study aimed to reveal the prevalence and consequences of unplanned stents in thoracic endovascular aortic repair for type B aortic dissection and explore the reasons, risk factors and solutions for unplanned stents. Methods Retrospectively analysis consecutive patients diagnosed as type B aortic dissection with initial tear originating distal from the left subclavian artery and underwent thoracic endovascular aortic repair from September 1998 to June 2014 in our center. Results Under the criteria, this study enrolled 322 patients, with 83 (25.8%) patients in unplanned group. The incidence rate of unplanned stents in thoracic endovascular aortic repair for type B aortic dissection in each year demonstrates as a bimodal curve. The curve showed that, 2003 and, 2004 was the first and highest peak and 2007 was the second peak. There was no difference in five-year survival rate between planned and unplanned patients (log-rank test, p = 0.994). The unplanned group had higher hospitalization expenses (142,699.08 ± 78,446.75 yuan vs. 175,238.58 ± 34,838.01 yuan; p = 0.019), longer operation time (104.50 ± 93.24 min vs. 179.08 ± 142.47 min; p < 0.001) and hospitalization time (17.07 ± 16.62 d vs. 24.00 ± 15.34 d; p = 0.001). The reasons for unplanned stents were type Ia endoleak (46 patients, 55.4%), bird beak (25 patients, 30.1%), and inappropriate shaping of stent (9 patients, 10.8%). Asymptomatic aortic dissection patients had higher incidence of unplanned stents. Short proximal neck length (2.66 ± 0.59 mm vs. 2.50 ± 0.51 mm; p = 0.016), short stent coverage length (154.62 ± 41.12 mm vs. 133.60 ± 44.33 mm; p = 0.002), and large distal stent oversize (75.44±10.77% vs. 82.68±15.80%; p <0.001) were risk factors for unplanned stents in thoracic endovascular aortic repair. Conclusion There are some special risk factors and reasons for unplanned stents in thoracic endovascular aortic repair for type B aortic dissection. Knowing these can we reduce the utilization of unplanned stents with appropriate methods.

Improved outcomes and value in staged hybrid extent II thoracoabdominal aortic aneurysm repair.

OBJECTIVE: Complex Crawford extent II thoracoabdominal aortic aneurysms (TAAAs) can be treated in a hybrid manner with proximal thoracic endovascular aneurysm repair, followed by staged distal open thoracoabdominal repair. This study evaluated the outcomes and health care-associated value of this new method compared with traditional open repair over 10 years. METHODS: A prospectively collected database was used to identify all patients with an extent II TAAA undergoing repair at a single institution between 2005 and 2015. Patient characteristics, postoperative outcomes, and incidence of major adverse events (MAEs; renal failure, spinal cord ischemia, death) were compared. After adjusting for time since surgery, value was analyzed looking at quality (1/MAE) divided by cost (total health system cost). This was multiplied by a constant to set the value of open TAAA repair to 100. RESULTS: A total of 113 consecutive patients underwent extent II TAAA repairs, of whom 25 (22.1%) had a staged hybrid approach with a median of 129 days between procedures. No baseline differences in demographic or comorbidity variables existed between groups (P > .05). The hybrid group had shorter operative time (255 vs 306 minutes; P = .01), shorter postoperative length of stay (10.1 vs 13.3 days; P = .02), and reduced blood loss (1300 vs 2600 mL; P = .01) at the time of open operation. Despite higher rates of acute kidney injury in the hybrid group (76.0% vs 51.1%; P = .03), there was no difference in renal failure (8.0% vs 4.5%; P = .84). The incidence of MAEs was lower in the staged hybrid group (20.0% vs 48.9%; P = .01), without a difference in hospital mortality (4.0% vs 3.4%; P = .89). Median total cost was higher in the hybrid group ($112,920 vs $72,037; P = .003). Value was improved in the hybrid group by 56% using mean cost and 178% by median cost. CONCLUSIONS: The 20% MAE rate associated with staged hybrid repair of extent II TAAA was significantly decreased compared with open repair, with a relative reduction of >50%. Despite higher total hospital costs, staged hybrid repair had 56% to 178% higher health care-related value compared with standard open repair. In an era of increasing focus on costs and quality, staged hybrid repair of extensive TAAAs is associated with fewer complications than open TAAA repair, resulting in a good value investment from a resource utilization perspective.

Contemporary economic and clinical evaluations of endovascular repair for intact descending thoracic aortic aneurysms.

BACKGROUND: The aim of this study was to assess clinical and contemporary costs associated with elective endovascular repair of intact descending thoracic aortic aneurysms (DTAA) into the mid-term follow-up. METHODS: A retrospective review of a prospectively maintained clinical database including 29 consecutive patients from July 2005 to December 2009 treated with elective endovascular repair (TEVAR) or TEVAR and surgical infrarenal repair (hybrid) of intact DTAA was performed. Mean age was 74.5 years old (±7.1). Primary clinical endpoints include mortality and major morbidity. Additionally a comprehensive economic appraisal of individual in-hospital and follow-up costs was executed. Economic endpoints include in-hospital and follow-up costs and patient discharge status. Elective endovascular and open repairs' clinical and economical outcomes in contemporary literature were assessed for comparison according to PRISMA standards. RESULTS: Immediate mortality was 6.9% (1/24 TEVAR and 1/5 hybrid). Three respiratory complications were recorded (11%; 2 TEVAR, 1 hybrid). Renal and cardiac complication rates were 7.4% (1 TEVAR, 1 hybrid) and 3.7% (1 TEVAR) respectively. Routine discharge home was achieved for 85% of patients (95.7% TEVAR, 25% hybrid). Three endoleaks were treated throughout the follow-up (2 TEVAR, 1 hybrid; mean 30.4 mo, ±19.9) rendering an 11% (3/27) reintervention rate. Average immediate cost was €21,976.87 for elective endovascular repair and €33,783.21 for elective endovascular hybrid repair. Additional reintervention and routine follow-up costs augmented immediate costs by 12.4%. CONCLUSIONS: This study supports satisfying immediate clinical outcomes for TEVAR and TEVAR+surgical infrarenal procedures. Although limited by a small population size and difficulties in economic comparisons, this study presents the real world social and economic cost scenario for both elective TEVAR and TEVAR hybrid treatment of DTAA of both the in-hospital and at mid term follow-up periods.

The Impact of Physician Specialization on Clinical and Hospital Outcomes in Patients Undergoing EVAR and TEVAR.

BACKGROUND: Endovascular aneurysm repair (EVAR) and Thoracic endovascular aortic repair (TEVAR) are commonly performed by interventional radiologists, cardiologists, general surgeons, cardiothoracic surgeons, and vascular surgeons, with each specialty having differences in residency structure, operative experience, and subspecialty training. The aim of this study is to evaluate the impact of surgeon specialty on outcomes following EVAR and TEVAR. METHODS: Patients who underwent EVAR and TEVAR were identified from the 2007 to 2009 Nationwide Inpatient Sample (NIS). Physician identifiers in the NIS were used to determine surgical specialty and operative experience. Multivariate analysis adjusted for mortality risk was used to compare differences in demographics, complications, outcomes, and hospital covariates. RESULTS: A total of 5147 EVARs were identified within the NIS, of which 88.3% were completed by vascular surgeons. There were no significant differences in demographics between the specialties. Cardiothoracic surgeons were more likely to have a postoperative stroke (3.1% vs. 0.2%, odds ratio [OR] 14.6, 95% confidence interval [CI] 1.8-117.8, P < 0.05) and cardiac complications (9.4% vs. 2.0%, OR 5.0, 95% CI 1.5-16.6, P < 0.01) compared with other specialties. Costs were lowest for vascular surgeons ($32,094), and highest for cardiothoracic surgeons ($41,663, P < 0.05). Only vascular surgeons completed more than 10 EVARs per year. A total of 2531 TEVAR cases were completed during the study period, of which 73.8% were completed by vascular surgeons, 15.8% by cardiothoracic surgeons, 8.0% by interventional radiologists, and the remainder by interventional cardiologists and general surgeons. Interventional radiologists had significantly more elective cases (77.8%, P < 0.001) than cardiothoracic surgeons (47.2%) or vascular surgeons (53.8%), but had a significantly higher rate of stroke (7.6% vs. 1.1%, P < 0.001) and cardiac events (7.2% vs. 3.6%, P < 0.001). Length of stay (LOS, 10.7 days) and median costs ($52,156) were similar across specialties. Vascular surgeons have a low stroke rate (1.1%, P < 0.05 vs. interventional radiologists) and lower rate of cardiac events (3.6% vs. 6.1%, P < 0.01) despite caring for patients with higher diagnosis-related group mortality scores (3.6 vs. 3.4, P < 0.05). CONCLUSIONS: Vascular surgeons appear to have a comparative advantage over other specialties for EVAR because not only are their complication and mortality rates comparable but overall LOS and hospital charges are lower. Furthermore, primarily only vascular surgeons are performing the high volume of annual EVARs necessary to ensure optimal patient outcomes. For TEVAR, vascular surgeons have the lowest overall morbidity compared with the other specialties, and lower mortality compared with cardiothoracic surgeons. These findings may impact patient referral patterns and hospital privileges for providers.

Editor's choice - thirty day outcomes and costs of fenestrated and branched stent grafts versus open repair for complex aortic aneurysms.

OBJECTIVE: To compare 30 day outcomes and costs of fenestrated and branched stent grafts (f/b EVAR) and open surgery (OSR) for the treatment of complex abdominal aortic aneurysms (AAA) and thoraco-abdominal aortic aneurysms (TAAA). METHODS: The multicenter prospective registry WINDOW was set up to evaluate f/b EVAR in high risk patients with para/juxtarenal AAA, and infradiaphragmatic and supradiaphragmatic TAAA. A control group of patients treated by OSR was extracted from the national hospital discharge database. The primary endpoint was 30 day mortality. Secondary endpoints included severe complications, length of stay, and costs. Mortality was assessed by survival analysis and uni/multivariate Cox regression analyses using pre- and post-operative characteristics. Bootstrap methods were used to estimate the cost-effectiveness of f/b EVAR versus OSR. RESULTS: Two hundred and sixty eight cases and 1,678 controls were included. There was no difference in 30 day mortality (6.7% vs. 5.4%, p = 0.40), but costs were higher with f/b EVAR (€38,212 vs. €16,497, p < .001). After group stratification, mortality was similar with both treatments for para/juxtarenal AAA (4.3% vs. 5.8%, p = .26) and supradiaphragmatic TAAA (11.9% vs. 19.7%, p = .70), and higher with f/b EVAR for infradiaphragmatic TAAA (11.9% vs. 4.0%, p = .010). Costs were higher with f/b EVAR for para/juxtarenal AAA (€34,425 vs. €14,907, p < .0001) and infradiaphragmatic TAAA (€37,927 vs. €17,530, p < .0001), but not different for supradiaphragmatic TAAA (€54,710 vs. €44,163, p = .18). CONCLUSION: f/b EVAR does not appear justified for patients with para/juxtarenal AAA and infradiaphragmatic TAAA fit for OSR but may be an attractive option for patients with para/juxtarenal AAA not eligible for surgery and patients with supradiaphragmatic TAAA. CLINICAL TRIAL REGISTRATION: http://www.clinicaltrials.gov/ct2/show/NCT01168037; identifier: NCT01168037 (WINDOW registry).

Outcomes following emergent open repair for thoracic aortic dissection are improved at higher volume centers.

BACKGROUND: Previous studies have demonstrated that patients undergoing complex surgical procedures at high-volume centers have improved outcomes. The goal of this study was to determine if this volume-outcomes relationship persists at a national level among patients undergoing emergent open repair for thoracic aortic dissection. METHODS: De-identified patient-level data were obtained from the Nationwide Inpatient Sample (2005 to 2008). Patients undergoing emergent aortic surgery for thoracic aortic dissection (n = 1230) were identified by ICD-9 codes and stratified by annual center volume into low volume (≤5 cases/year), intermediate volume (6 to 10 cases/year), and high volume (≥11 cases/year). The Deyo-Charlson co-morbidity score was used to adjust for differences in comorbidity between groups. Major outcomes of interest included: in-hospital morbidity and mortality, length of hospitalization, total hospital costs, and discharge disposition. RESULTS: There was a significant association between in-hospital mortality and center volume (p = 0.014), with low, intermediate, and high-volume centers having mortality rates of 23.4% (n = 187), 20.1% (n = 62), and 12.1% (n = 15), respectively. This relationship persisted when controlling for severity of co-morbid illness (p = 0.007). The number of complications per patient varied significantly by center volume (p = 0.044), with a higher proportion of patients at high-volume centers having no complications. Also, the highest proportion of home discharges was observed among patients at high-volume centers (p = 0.011). CONCLUSIONS: Survival following emergent open repair for thoracic aortic dissection was significantly greater at high-volume centers. These findings suggest that understanding the processes at high-volume centers that underlie this volume-outcomes relationship may improve in-hospital survival and postoperative complications.

Cost analysis of endovascular versus open repair in the treatment of thoracic aortic aneurysms.

OBJECTIVE: For descending thoracic aortic aneurysms (TAAs), it is generally considered that thoracic endovascular aortic repairs (TEVARs) reduce operative morbidity and mortality compared with open surgical repair. However, long-term differences in survival of patients have not been demonstrated, and an increased need for aortic reintervention has been observed. Many assume that TEVAR becomes less cost-effective through time because of higher rates of reintervention and surveillance imaging. This study investigated midterm outcomes and hospital costs of TEVAR compared with open TAA repair. METHODS: This was a retrospective, single-institution review of elective TAA repairs between 2005 and 2012. Patient demographics, operative outcomes, reintervention rates, and hospital costs were assessed. The literature was also reviewed to determine commonly observed complication and reintervention rates for TEVAR and open repair. Monte Carlo simulation was used to model and to forecast hospital costs for TEVAR and open TAA repair up to 3 years after intervention. RESULTS: Our cohort consisted of 131 TEVARs and 27 open repairs. TEVAR patients were significantly older (67.2 vs 58.7 years old; P = .02) and trended toward a more severe comorbidity profile. Operative mortality for TEVAR and open repair was 5.3% and 3.7%, respectively (P = 1.0). There was a trend toward more complications in the TEVAR group, although not statistically significant (all P > .05). In-hospital costs were significantly greater in the TEVAR group ($52,008 vs $37,172; P = .001). However, cost modeling by use of reported complication and reintervention rates from the literature overlaid with our cost data produced a higher cost for the open group in-hospital ($55,109 vs $48,006) and at 3 years ($58,426 vs $52,825). Interestingly, TEVAR hospital costs, not reintervention rates, were the most significant driver of cost in the TEVAR group. CONCLUSIONS: Our institutional data showed a trend toward lower mortality and complication rates with open TAA repair, with significantly lower costs within this cohort compared with TEVAR. These findings were likely, at least in part, to be due to the milder comorbidity profile of these patients. In contrast, cost modeling by Monte Carlo simulation demonstrated lower costs with TEVAR compared with open repair at all time points up to 3 years after intervention. Our institutional data show that with appropriate selection of patients, open repair can be performed safely with low complication rates comparable to those of TEVAR. The cost model argues that despite the costs associated with more frequent surveillance imaging and reinterventions, TEVAR remains the more cost-effective option even years after TAA repair.

Readmissions after complex aneurysm repair are frequent, costly, and primarily at nonindex hospitals.

OBJECTIVE: Readmissions after complex vascular surgery are not well studied. We sought to determine the rate of readmission after thoracic and thoracoabdominal aortic aneurysm repair (TAA/TAAAR) at our institution and to identify risk factors for and costs of readmission. METHODS: Using a prospectively collected institutional database in conjunction with a Maryland statewide database, we reviewed index admissions and early readmissions for all patients who underwent TAA/TAAAR between 2002 and 2013 at the Johns Hopkins Hospital. Only Maryland residents were included to capture readmissions to any Maryland hospital. RESULTS: We identified 115 Maryland residents (58% men; mean age, 65 ± 1.2 years) undergoing TAA/TAAAR (57% open repair). Early readmissions were frequent and occurred in 29% of patients. Of the readmitted patients, 79% (P < .001) were not readmitted to the index hospital where their operation was performed. Readmitted patients were not significantly different from nonreadmitted patients in age, gender, race, aneurysm type, and index length of stay. They were not different in preoperative comorbidities (including coronary artery disease, diabetes mellitus, smoking, renal insufficiency, and pulmonary disease), postoperative neurologic, renal, and cardiovascular complications, or 30-day or 5-year mortality. Multivariable analysis showed that significant risk factors for readmission were open repair (odds ratio, 3.12; 95% confidence interval, 1.12-9.54; P = .03) and postoperative pneumonia (odds ratio, 4.31; 95% confidence interval, 1.28-15.4; P = .02). Readmitted patients had significantly lower average income compared with the nonreadmitted cohort (U.S. $62,000 ± $4000 vs $73,000 ± $3000; P = .04). Striking differences were seen between patients readmitted to the index hospital where the operation was performed, and those who were readmitted to a nonindex hospital: patients readmitted to the index hospital were readmitted mainly for aneurysm-related surgical issues, whereas patients readmitted to the nonindex hospital were readmitted for medical morbidities. An aneurysm-related intervention was required in 75% of patients readmitted to the index hospital vs in 9% of patients readmitted to the nonindex hospital. Readmissions to a nonindex hospital cost significantly less than to the index hospital (U.S. $20,000 ± $4400 vs $42,000 ± $8800; P = .03) and were not associated with increased overall mortality. CONCLUSIONS: Early readmissions after TAA/TAAA repair are frequent and often occur at hospitals other than the index institution. Risk factors for readmission include open repair and postoperative pneumonia but not pre-existing patient comorbidities. Readmissions to nonindex hospitals were related to medical morbidities that were associated with fewer interventions and lower costs compared with the index hospital. Focusing on preoperative risk factors in this group of patients may not lead to reduction in readmissions. Minimizing nonsurgical complications may reduce post-TAA/TAAAR readmissions and the high costs associated with repeat care.