National Inpatient Sample Used to Evaluate Impact of TEVAR on Ruptured TAA Management and Outcomes
August 9, 2017—Marc L. Schermerhorn, MD, led a study to assess national trends in the use of thoracic endovascular aortic repair (TEVAR) for the treatment of ruptured thoracic aortic aneurysms (rTAAs) and to determine its impact on perioperative outcomes. The findings were published by Klaas H.J. Ultee, BSc, et al in Journal of Vascular Surgery (2017;66:343–352).
The investigators concluded that TEVAR has replaced open repair as the primary operative treatment for rTAA and that the introduction of endovascular treatment appears to have broadened the eligibility of patients for operative treatment, particularly among the elderly. Mortality after rTAA admission has declined since the introduction of TEVAR, which is the result of improved operative mortality as well as the increased proportion of patients undergoing repair.
The investigators identified patients admitted with rTAAs between 1993 and 2012 in the National Inpatient Sample. Patients were grouped according to their treatment: TEVAR, open repair, or nonoperative treatment. The primary outcomes were treatment trends over time and in-hospital death. Secondary outcomes included perioperative complications and length of hospital stay. Trend analyses were performed using the Cochran-Armitage test for trend, and adjusted mortality risks were established using multivariable logistic regression analysis.
As summarized in Journal of Vascular Surgery, the study was composed of 12,399 patients (1,622 [13%] undergoing TEVAR; 2,808 [23%] undergoing open repair; and 7,969 [64%] not undergoing operative treatment).
The investigators found that TEVAR has been increasingly used from 2% of total admissions in 2003 to 2004 to 43% in 2011 to 2012 (P < .001). Concurrently, there was a decline in the proportion of patients undergoing open repair (29% to 12%; P < .001) and nonoperative treatment (69% to 45%; P < .001).
The proportion of patients undergoing operative repair has increased for all age groups since 1993 to 1994 (P < .001 for all) but was most pronounced among those in the 80-year-old age range with a 7.5-fold increase.
After TEVAR was introduced, procedural mortality decreased from 36% in 2003 to 2004 to 27% in 2011 to 2012 (P < .001); mortality among those undergoing nonoperative treatment remained stable (between 63% and 60%; P = .167).
Overall mortality after rTAA admission decreased from 55% to 42% (P < .001). Since 2005, mortality for open repair was 33% and was 22% for TEVAR (P < .001).
In adjusted analysis, open repair was associated with a two-fold higher mortality rate than TEVAR (odds ratio, 2; 95% confidence interval, 1.7–2.5), reported the investigators in Journal of Vascular Surgery.