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TEVAR vs. Open Repair of the Descending Thoracic Aorta
Study Questions:
What is the comparative effectiveness of thoracic endovascular aortic repair (TEVAR) and open surgical repair in the treatment of intact descending thoracic aortic aneurysms?
Methods:
The investigators, using the Medicare database, conducted a retrospective study using regression discontinuity design and propensity score matching on patients with intact descending thoracic aortic aneurysms who underwent TEVAR or open surgical repair between 1999 and 2010, with follow-up through 2014. Survival was assessed with restricted mean survival time. Perioperative mortality was assessed with logistic regression. Reintervention was evaluated as a secondary outcome.
Results:
Matching created comparable groups with 1,235 open surgical repair patients matched to 2,470 TEVAR patients. The odds of perioperative mortality were greater for open surgical repair: high-volume center, odds ratio (OR), 1.97 (95% confidence interval [CI], 1.53-2.61); low-volume center, OR, 3.62 (95% CI, 2.88-4.51). The restricted mean survival time difference favored TEVAR at 9 years, -209.2 days (95% CI, -298.7 to -119.7 days; p < 0.001) for open surgical repair. Risk of reintervention was lower for open surgical repair, hazard ratio, 0.40 (95% CI, 0.34-0.60; p < 0.001).
Conclusions:
The authors concluded that open surgical repair was associated with increased odds of early postoperative mortality, but reduced late hazard of death.
Perspective:
This study reports that open surgical repair was associated with higher early mortality than TEVAR, but the late hazard of death and risk of reintervention were lower among patients who underwent open surgical repair. However, despite the potential improved durability of open surgical repair, the initial mortality advantage of TEVAR over open surgical repair persisted until 9 years postoperatively, resulting in a significant survival benefit associated with TEVAR. Given the mortality advantage observed in patients undergoing TEVAR over open surgical repair, TEVAR appears to be the preferred treatment modality for thoracic aortic aneurysms, with additional studies indicated to determine the optimal timing of intervention.
Clinical Topics: Cardiac Surgery, Geriatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Prevention, Vascular Medicine, Aortic Surgery, Cardiac Surgery and Arrhythmias, Interventions and Vascular Medicine
Keywords: Aortic Aneurysm, Aortic Aneurysm, Thoracic, Cardiac Surgical Procedures, Cardiology Interventions, Endovascular Procedures, Geriatrics, Primary Prevention, Survival Rate, Treatment Outcome, Vascular Diseases
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