National trends and regional variation of open and endovascular repair of thoracic and thoracoabdominal aneurysms in contemporary practice

Abstract

Objectives Successful surgical management of thoracic aortic aneurysms (TAA) and thoracoabdominal aortic aneurysms (TAAA) has historically relied upon open surgical repair (OSR). More recently, the advent and application of thoracic endovascular stent graft aneurysm repair (TEVAR) permutations have become increasingly performed in contemporary practice. To better determine the effect of TEVAR techniques on OSR, we examined national and regional trends in treatment use. Methods All Medicare patients from 1998 through 2007 undergoing isolated TAA and TAAA repair were analyzed using a clinically validated algorithm using diagnostic International Classification of Disease 9th revision (ICD-9; 441.1, 441.2, 441.6, 441.7, 441.9) codes and procedural (ICD-9 OSR: 38.35, 38.45 and TEVAR: 39.73, 39.79) codes. Differential rates of OSR and TEVAR were compared across census tract regions during the study interval. Results Total complex aortic repairs increased by 60%, from 10.8 to 17.8/100,000, between 1998 and 2007 (P <.001). A dramatic increase occurred in TEVAR (not performed in 1998, 5.8/100,000 in 2007) during the study period, but OSR rates remained stable during the same interval (10.7 to 12.0/100,000 in 2007, P < NS). There was substantial regional variation for both OSR and TEVAR. This regional variation was greater in OSR (range, 8.8–16.7/100,000) than in TEVAR (range, 4.5–6.9/100,000). Conclusions Degenerative TAA and TAAA aneurysms are being repaired in the United States at an increasing rate. This reflects the rapid acceptance of TEVAR, which apparently supplements rather than supplants OSR. There appears to be greater regional variation in OSR compared with TEVAR. These data may have significant implications for those interested in the effect of new technologies on health care and cost containment.

Aortic Pathology Determines Midterm Outcome After Endovascular Repair of the Thoracic Aorta

“…In recent years, the number of thoracic endovascular procedures has risen. 1,2 The increased use of TEVAR has been driven by the early mortality advantage reported when endovascular therapy is compared with open surgical treatment of the thoracic aorta. 3,4 TEVAR is now considered the first-line therapy for isolated aneurysms of the descending thoracic aorta and acute complicated type B aortic dissections.…”

What Can We Learn From MOTHER?

“…It is estimated that currently, off-label applications constitute well over half of all TEVRs. 7,8 Although the use of TEVR as a definitive treatment for either acute 9 or chronic 10 aortic dissection remains controversial, its use in emergent, complicated cases of acute DeBakey type III aortic dissection is generally considered acceptable and potentially lifesaving; in fact, in many programs, TEVR has become the treatment of choice for such cases. 11 Patterson and colleagues 12 are to be commended for reporting outcomes from one of the largest nonadministrative series of TEVRs (n=1010) in the current issue of From the 1010 patients in the series, the authors selected all those treated for aneurysm (n=670), chronic dissection (>2 weeks since onset; n=195), or acute dissection (≤2 weeks since onset; n=114), so the study cohort comprised 979 patients.…”

“…7,8 Rather, the overall number of patients treated for thoracic aortic pathology has increased, perhaps because many patients previously considered at prohibitive risk for open repair, as well as patients with acute aortic dissection who were once treated by medical management alone, are now being treated endovascularly. 7,8 Goodney et al 20 found that Medicare patients treated with TEVR often have worse long-term survival than open-repair patients. The long-term mortality data in the present study by Patterson et al 12 are similarly sobering: The rate of all-cause death at 5 years was 56% in the aneurysm group, 64% in the chronic dissection group, and 42% in the acute dissection group.…”

Long-Term Survival After Open Repair and Thoracic Endovascular Aortic Repair for Descending Thoracic Aortic Aneurysms

“…Indeed, we documented this very finding in an analysis of practice patterns and patient outcomes following DTA repair by the use of a more limited cohort (2004 -2007) of Medicare patients. 14 We reported an increase in the number of DTA repairs within 2 years after stent graft availability and a shift in practice from predominantly open repair of intact DTA in 2004 (75% open/25% TEVAR; nϭ1400) to a majority of patients being treated with TEVAR (40% open/60% TEVAR; nϭ2032) by 2007. This paradigm shift was also seen in patients with ruptured DTA, traumatic thoracic aortic injury, and aortic dissection; all are diagnoses for which TEVAR currently represents off-label use.…”

“…As such, TEVAR has supplanted open surgical repair in the majority of patients with DTA. 14,15 Article see p 2661…”