P Narayan, A Wong, I Davies, A J Bryan, P Wilde, G J Murphy

Does TEVAR provide a financial benefit for management of descending thoracic aortic

pathologies?

Background Management of descending aortic pathology is a

complex and challenging area

Surgical management is indicated in specific situations

Endo-Vascular Surgical Repair [TEVAR] provides another important option

Aim To assess early and mid term outcomes of TEVAR

compared with surgical repair

To compare the financial implications of TEVAR and surgical management

Methods Retrospective study

Time period: April 1996- February 2009

85 procedures

Surgical repair: 35

TEVAR: 49

Data accessed from computerised database –PATS System

and validated by case note reviews

Hospital costs calculated from NHS reference costs for staff time,

consumables, transfusion and length of stay.

Statistical Analysis

Data tabulated as N(%) for categorical data and median (inter-

quartile range) for continuous data

Continuous variables analysed with Mann Whitney U test

Categorical variables analysed with Fisher’s exact test or Chi-

square

Kaplan-Meier estimates were used to compare re- intervention

and survival

Trends in the Management of Descending Thoracic Aortic Pathology

Patient CharacteristicsSurgery (n=35) TEVAR (n=49) P value

Age (years) 55.5(33-67.5) 57.5(40.25-72) 0.210

Male 29 (81%) 34 (69%) 0.245

Pre op Neurological dysfunction

1(2%) 2(4%) 0.625

Previous cardiac surgery 10(27%) 12(24%) 0.818

COAD 3(8%) 4(8%) 0.607

Pre-op Renal Impairment 2(5%) 6(12%) 0.270

Current Smoker 20(55%) 23(47%) 0.356

Marfan 1(2%) 3(6%) 0.432

Diabetes 1(2%) 1(2%) 0.683

Hypertension 19(53%) 23(47%) 0.595

EuroScore 10(7-10) 9(8-10) 0.562

Emergency 12 (33%) 21 (43%) 0.047

Critical Preoperative State 12 (34%) 16 (33%) 0.876

Procedural Characteristics

Surgery TEVAR p value

Operative Sessions 2 (2.0-2.3) 1 (1-1) <0.0001

Aneurysm 19 (53%) 22 (45%) 0.473

Thoracoabdominal 7 (19%) 5 (10%) 0.148

Arch 5 (14%) 0 0.011

Dissection 10 (28%) 17(35%) 0.499

Acute 5 (14%) 16 (33%) 0.047

Chronic 5 (14%) 1 (2%) 0.047

Trauma 5 (14%) 7 (14%) 0.303

Other 2 (5%) 3 (6%) 0.707

RBC Transfusion 8(3-12) 0(0-3) <0.0001

Platelet Transfusion 2(0-3) 0(0-0) <0.0001

FFP Transfusion 2(0-8) 0(0-0) <0.0001

In Hospital Clinical OutcomeSurgery (n=35) TEVAR(n=49) P value

Atrial Fibrillation 12(33%) 1(2%) <0.0001

Inotropic Support 17(47%) 1(2%) <0.001

Neurological Complication 9(25%) 6(12%) 0.244

Renal Complication 11(31%) 5(10%) 0.025

GI Complication 5(14%) 5(10%) 0.513

Chest Infection 9(25%) 1(2%) 0.001

ARDS 2(5%) 0(0%) 0.159

Re-intubation 5(14%) 3(6%) 0.253

Tracheostomy 8(22%) 2(4%) 0.020

ITU Stay 6(3-11) 1(1-4) <0.0001

Hospital Stay 16(9-26) 10(6-17) 0.022

In Hospital Death 7(20%) 3(6%) 0.03

Hospitalisation Costs of EVAR versus Surgery

Cost Surgery (£) TEVAR(£) p value

Staff Costs 1836 (1836-2075) 1433 (1433-1433) <0.0001

Consumable/ Stent Costs 412 (216-696) 8000 (8000-10000) <0.0001

Procedure Cost 2468 (2260-3168) 9581 (9581-11581) <0.0001

Transfusion Costs 1327 (531-2124) 0 (0-531) <0.0001

ICU Costs 7200 (3600-13200) 2400 (1200-6000) <0.0001

Hospitalisation Cost 10400 (5238-22500) 5350 (3200-8150) 0.001

Total Cost 15045 (9299-27571) 16694 (13532-21729) 0.414

Mid-term Follow-up

Surgery (n=35) TEVAR (n=49)

Reintervention 1 (3%) 9 (18%)

Death 11 (31%) 10(20%)

Death or Reintervention

11 (31%) 18 (37%)

Mid-term Outcomes of TEVAR and Surgery for Diseases of the Descending Thoracic Aorta

Surgery

TEVAR

Surgery

TEVAR

Mortality Re-intervention

Log Rank p=0.002Log Rank p=0.901

Conclusions

TEVAR is associated with superior short-term results

Mid term survival is similar to surgery

Re-intervention rate is significantly higher in TEVAR

Resource utilisation is similar in both groups for the primary procedure

Costs may prove to be higher in the TEVAR group with re-interventions