Author + information
- Received August 6, 2018
- Revision received October 22, 2018
- Accepted October 30, 2018
- Published online February 11, 2019.
- Peter Chiu, MDa,b,
- Andrew B. Goldstone, MD, PhDa,b,
- Justin M. Schaffer, MDc,
- Bharathi Lingala, PhDa,
- D. Craig Miller, MDa,
- R. Scott Mitchell, MDa,
- Y. Joseph Woo, MDa,
- Michael P. Fischbein, MD, PhDa and
- Michael D. Dake, MDa,∗ (, )@StanfordMed
- aDepartment of Cardiothoracic Surgery, Stanford University, School of Medicine, Stanford, California
- bDepartment of Health and Research Policy, Stanford University, School of Medicine, Stanford, California
- cThe Heart Hospital Baylor Plano, Plano, Texas
- ↵∗Address for correspondence:
Dr. Michael D. Dake, Stanford University Medical School, Falk CV Research Center, 300 Pasteur Drive, Stanford, California 94305.
Background For the management of descending thoracic aortic aneurysms, recent evidence has suggested that outcomes of open surgical repair may surpass thoracic endovascular aortic repair (TEVAR) in as early as 2 years.
Objectives The purpose of this study was to evaluate the comparative effectiveness of TEVAR and open surgical repair in the treatment of intact descending thoracic aortic aneurysms.
Methods Using the Medicare database, a retrospective study using regression discontinuity design and propensity score matching was performed 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 to 2.61); low-volume center, OR: 3.62 (95% CI: 2.88 to 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 to 0.60; p < 0.001).
Conclusions Open surgical repair was associated with increased odds of early postoperative mortality but reduced late hazard of death. Despite the late advantage of open repair, mean survival was superior for TEVAR. TEVAR should be considered the first line for repair of intact descending thoracic aortic aneurysms in Medicare beneficiaries.
This work was conducted with support from a KL2 (to Dr. Chiu) and TL1 (to Dr. Goldstone) Mentored Career Development Award of the Stanford Clinical and Translational Science Award to Spectrum (National Institutes of Health [NIH] KL2 TR 001083, NIH TL1 TR 001084, NIH TR 001085). The funder had no involvement in the design or conduct of the study; in the collection, analysis, or interpretation of the data; or in the preparation, review, or approval of the manuscript. Dr. Miller has served as co-Principal Investigator for the Abbott Vascular COAPT MitraClip Trial, Stanford Principal Investigator for the COMMENCE Trial and PARTNER I, II, and III Trials, Edwards Lifesciences, and Stanford Principal Investigator for the Medtronic SURTAVI Trial; has served as a consultant for Medtronic; and has served on the executive committee of Edwards Lifesciences. Dr. Mitchell has received consulting fees from W.L. Gore. Dr. Dake has received consulting fees from W.L. Gore, Abbott Vascular, and Medtronic; and has received consulting and lecture fees from Cook Medical. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Listen to this manuscript's audio summary by Editor-in-Chief Dr. Valentin Fuster on JACC.org.
- Received August 6, 2018.
- Revision received October 22, 2018.
- Accepted October 30, 2018.
- 2019 American College of Cardiology Foundation
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