December 12, 2008

Early Outcomes of Endovascular versus Open Thoracic Aortic Aneurysm Repair in the National Surgical Quality Improvement Program (NSQIP)

Mark F. Conrad, MD, Robert T. Lancaster, MD, Ugwuji N. Maduekwe, MD, Matthew Hutter, MD, Christopher J. Kwolek, MD, Richard P. Cambria, MD.
Massachusetts General Hospital, Boston, MA, USA.

Objective: Comparative trials of endovascular (TEVAR) and open (OPEN) thoracic aneurysm repair (TAR) have produced disparate results. We report 30-day outcomes of OPEN and TEVAR from a prospectively collected, validated, multicenter database. Methods: All patients who underwent TEVAR and open TAR during the years 2005 and 2006 were identified by CPT code from the National Surgical Quality Improvement Program (NSQIP) participant use file. Pre-operative variables and 30 day post-operative results were collected and evaluated using univariate and multivariate methods. Complications were stratified into categorical “buckets” for evaluation of outcomes. Results: There were 331 patients identified who underwent elective TAR (174 TEVAR and 157 OPEN) during the study period. Demographic factors were similar between the two groups. Although 30-day mortality was similar, (8.1% TEVAR, 9.6%OPEN, p=0.70), the overall complication rate was significantly higher after open repair (30% TEVAR, 61% OPEN, p<0.001) as was the median length of stay (4 days TEVAR, 10 days OPEN, p<0.001). OPEN had a higher incidence of infectious complications (16.7% TEVAR, 40.8% OPEN, p<0.001), pulmonary events (17.8% TEVAR, 54.8%OPEN, p<0.001) and renal complications (4%TEVAR, 17.2% OPEN, p<0.001). There was no difference in neurologic events (6.3% TEVAR. 5.7%OPEN). The main components contributing to pulmonary complications were pneumonia (8.1% TEVAR, 33.1%OPEN, p<0.001) and mechanical ventilation >48 hours (12.1% TEVAR, 46.5%OPEN, p<0.001). Multivariate predictors of pulmonary complications included: TEVAR (protective) (odds ratio(OR) 0.178, 95% confidence interval(CI) 0.10-0.30, p <0.001), History of COPD (OR 2.04, CI 1.12-3.7, p=0.02), unclean wound class (OR 4.732, CI 1.41-15.87, p=0.01) and preoperative sepsis (OR 3.4, CI 1.5-7.78, p=0.004). Conclusions: The NSQIP results demonstrate that although there was no early mortality advantage for TEVAR vs. OPEN, the overall complication rate after TEVAR was half that of open repair. These data support the posture that TEVAR should be first line therapy for anatomically appropriate patients with TAR.

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