Management of Diseases of the Descending Thoracic Aorta in the Endovascular Era: A Medicare Population Study
*Mark F Conrad, *Emel A Ergul, *Virendra I Patel, *Christopher J Kwolek, Richard P Cambria
Massachusetts General Hospital, Boston, MA
OBJECTIVE(S):Prospective trials have shown improved peri-operative mortality with endovascular repair of thoracic aortic pathologies(TEVAR) compared to conventional surgery(OPEN). However, there are currently no long-term population data detailing the impact of TEVAR on practice patterns and mortality rates for treatment of descending thoracic aortic pathology(DTA); which is the goal of this study.
METHODS:All procedures performed on the DTA captured in the Medicare database from 2004-2007 were identified by ICD-9 codes and stratified into OPEN and TEVAR cohorts. Outcomes included peri-operative mortality (chi-square) and 5-year actuarial survival.
RESULTS:There were 11166 patients identified(4838(43%)TEVAR, 6328(57%)OPEN) with 7247(65%) non-ruptured aneurysms(TAA), 2701(24%) dissections, 1033(9%) ruptures and 185(2%) traumatic aortic tears. The distribution of cases changed significantly during the study period(p<0.0001) with an increase in TEVAR, decrease in OPEN, and increase in total cases over time(Table). The peri-operative mortality was lower in the TEVAR group for the entire population(360(7.4%)TEVAR vs. 1175(18.5%)OPEN,p<0.0001), and for the individual pathologies: TAA(182/3529(5%)TEVAR,451/3718(12%)OPEN,p<0.001), dissections(76/833(9%)TEVAR,399/1868(21%)OPEN,p<0.001), ruptures(87/368(24%)TEVAR,298/665(45%)OPEN,p<0.0001). The 5 year survival (all curves significantly favored TEVAR due to perioperative mortality) by indication was: entire population (53.4%TEVAR,53.3%OPEN), TAA(55.8%TEVAR,59.7%OPEN), dissection(58.2%TEVAR,50.6%OPEN) and ruptures(23.3%TEVAR,25.3%OPEN).
CONCLUSIONS:There has been a significant increase in the use of TEVAR to manage disease of the descending thoracic aorta. TEVAR offers a significant peri-operative survival advantage when compared to OPEN regardless of the indication for repair. However, in the Medicare population, the 5-year survival is similar between the two cohorts.
|2004||467 (21%)||1798 (79%)||2265|
|2005||1012 (38%)||1627 (62%)||2639|
|2006||1630 (52%)||1503 (48%)||3133|
|2007||1729 (55%)||1400 (45%)||3129|
|Totals||4838 (43%)||6328 (57%)||11166|