Survival after open versus endovascular thoracic aortic aneurysm repair in an observational study of the Medicare population

Abstract

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.

Figure 1

Establishing the cohort of patients undergoing TAA repair.

Figure 2

In-hospital or 30-day survival following TAA repair.

Figure 3

Figure 3a. Unadjusted five-year survival in thoracic aneurysms, by procedure type and diagnosis. Figure 3b. Adjusted five-year survival in thoracic aneurysms, by procedure type and diagnosis. Results represent male, non-black patients under age 75 with Charlson score <2, performed after 2003. Figure 3c. Propensity-matched five year survival in thoracic aneurysms, by procedure type. These patients represent a randomly selected, propensity-matched sample of low-risk patients who are at equal likelihood of undergoing either open repair or TEVAR.

Figure 3

Figure 3a. Unadjusted five-year survival in thoracic aneurysms, by procedure type and diagnosis. Figure 3b. Adjusted five-year survival in thoracic aneurysms, by procedure type and diagnosis. Results represent male, non-black patients under age 75 with Charlson score <2, performed after 2003. Figure 3c. Propensity-matched five year survival in thoracic aneurysms, by procedure type. These patients represent a randomly selected, propensity-matched sample of low-risk patients who are at equal likelihood of undergoing either open repair or TEVAR.

Figure 3

Figure 3a. Unadjusted five-year survival in thoracic aneurysms, by procedure type and diagnosis. Figure 3b. Adjusted five-year survival in thoracic aneurysms, by procedure type and diagnosis. Results represent male, non-black patients under age 75 with Charlson score <2, performed after 2003. Figure 3c. Propensity-matched five year survival in thoracic aneurysms, by procedure type. These patients represent a randomly selected, propensity-matched sample of low-risk patients who are at equal likelihood of undergoing either open repair or TEVAR.