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In ‘real-world’ practice, endovascular repair of thoracic aortic aneurysms (TEVAR) lowers the risk of periprocedural mortality compared with open surgery, but over the long term, survival is improved with a surgical approach, according to an observational study published online November 21, 2011, ahead of print in Circulation. The authors call for further investigation to determine whether patients with marked comorbidities are unlikely to benefit from TEVAR.

Philip P. Goodney, MD, of Dartmouth-Hitchcock Medical Center (Lebanon, NH), and colleagues analyzed Medicare claims from 1998 to 2007 to compare outcomes of patients with descending thoracic aortic aneurysms (TAA) treated with open repair or TEVAR. Among 15,305 patients identified, 12,573 underwent open repair (11,564 intact, 1,008 ruptured) and 2,732 received TEVAR (2,433 intact, 299 ruptured).

Perioperative mortality (in-hospital or within 30 days) was lower for patients who underwent TEVAR regardless of whether the aneurysm was intact or ruptured (table 1).

Table 1. Perioperative Mortality: Open Repair vs. TEVAR by Aneurysm Status

Over the long term, however, the pattern reversed in patients with intact aneurysms. At 5 years, survival was lower in those who received TEVAR compared with open surgery. Among patients with ruptured aneurysms, survival rates were similar for the 2 strategies (table 2).

Table 2. Estimated 5-Year Survival: Open Repair vs. TEVAR by Aneurysm Status

Results Similar in Adjusted Analyses

Results were similar after adjustment for age, sex, race, era of procedure, and Charlson comorbidity score. Among patients with intact aneurysms, perioperative mortality was lower with TEVAR, but this benefit disappeared by 1 year, and mortality was significantly worse at 5 years. Among patients with ruptured aneurysms, an initial survival advantage with TEVAR disappeared by 90 days, and again mortality was worse with TEVAR by the end of 5 years

In propensity-matched analysis, both types of repair initially resulted in similar mortality rates, but patients who received open repair enjoyed a clear survival advantage by 5 years.

In a separate analysis, the investigators compared rates of perioperative mortality and 3-year survival before and after approval by the US Food and Drug Administration (FDA) of a device specifically designed for TEVAR. Although no differences were seen in patient characteristics or short- and long-term outcomes for TEVAR patients, after approval, patients who received open repair had a lower Charlson comorbidity score, and perioperative mortality declined and 3-year survival increased in open surgical patients (both P = 0.0001).

According to the authors, these data suggest that after FDA approval, patients selected for open repair were lower risk than those selected for TEVAR, although this conclusion requires confirmation in studies amenable to risk adjustment. 

Better Patient Selection for TEVAR Needed

The long-term mortality disadvantage of TEVAR in intact aneurysms might be due to migration, endoleaks, or defects within the device itself, said Dr. Goodney in an e-mail correspondence with TCTMD.

“However, none of these issues have become apparent across a variety of high-quality clinical trials,” he observed. “Therefore, we believe TEVAR results in greater long-term mortality in real-world practice because patients selected for TEVAR have a greater burden of comorbidities as compared to those selected for open repair. One might argue that [some of] these patients were more likely to die in the near term from their comorbidities, with an intact [aneurysm], rather than from [aneurysm] rupture.

“Given the significant cost surrounding this increasingly utilized procedure, our study highlights the need to improve patient selection for TEVAR so that patients survive long enough to benefit from it,” Dr. Goodney concluded.

Source:

Goodney PP, Travis L, Lucas FL, et al. Survival after open versus endovascular thoracic aortic aneurysm repair in an observational study of the Medicare population. Circulation. 2011;124:2661-2669.

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