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

Abstract

Objective For descending thoracic aortic aneurysms (TAAs), it is generally considered that endovascular stents (TEVARs) reduce operative morbidity and mortality compared to open surgical repair. However, long-term differences in patient survival have not been demonstrated, and an increased need for aortic reintervention has been observed. Many assume that TEVAR becomes less cost effective through time due to higher rates of reintervention and surveillance imaging. This study investigated mid-term outcomes and hospital costs of TEVAR compared with open TAA repair. Methods This was a retrospective, single institution review of elective thoracic aortic aneurysm 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 utilized to model and forecast hospital costs for TEVAR and open TAA repair up to 3 years post-intervention. Results Our cohort consisted of 131 TEVARs and 27 open repairs. TEVAR patients were significantly older (67.2 vs. 58.7, p=0.02) and trended towards 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 towards more complications in the TEVAR group, although not statistically significant (all p>0.05). In-hospital costs were significantly greater in the TEVAR group ($52,008 vs. $37,172, p=0.001). However, cost modeling utilizing 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 to TEVAR. These findings were likely at least in part due to the milder comorbidity profile within these patients. In contrast, cost modeling using Monte Carlo simulation demonstrated lower costs with TEVAR compared to open repair at all time points up to 3 years post-intervention. Our institutional data shows that with appropriate patient selection, open repair can be performed safely with low complication rates comparable to 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.

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

“…32 This is not surprising considering almost 50% requiring a carotid-subclavian bypass. This not only impacted the cost, but also resulted in a 6 day median length of stay.…”

Type 2 Diabetes Mellitus and Thoracic Aortic Aneurysm and Dissection

“…Our results are consistent with those reported in the literature, indicating higher perioperative mortality for OSR. 23 , 24 In 2011, Goodney et al 23 found that perioperative mortality was lower in patients undergoing TEVAR than in patients undergoing OSR for both intact TAA (6.1 vs 7.1%; P < 0.05) and ruptured TAA (28 vs 46%; P < 0.01). In the USA, Hughes et al 8 compared the results of OSR with those of TEVAR and reported that, after adjustment for preoperative comorbidities, including the presence of diabetes, the likelihood of death was reduced by 46% among patients undergoing endovascular repair compared with OSR (OR 0.54; P < 0.01).…”

A reproducible swine model of proximal descending thoracic aortic aneurysm created with intra-adventitial application of elastase

“…4,5 However, endovascular repair is restricted by abnormal anatomy, especially when TAA involves the aortic arch and proximal descending aorta. 6,7 Despite great improvement in surgical repair for the treatment of TAA, up to one-third of patients cannot tolerate surgical procedures because of the high risk of complications and invasiveness. 8,9 Considering the potential limitations of surgical and endovascular repair, a deep understanding of the cellular and molecular mechanisms of TAA is necessary in the case of proximal descending aortic aneurysm.…”