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Outcomes and Cost of Open Versus Endovascular Repair of Intact Thoracoabdominal Aortic Aneurysm.
Satinderjit S. Locham, MD, Jasninder Dhaliwal, MD, Hanaa Dakour Aridi, MD, Besma Nejim, MD, MPH, Widian Alshwaily, MD, Mahmoud Malas, MD, MHS.
John Hopkins Hospital, Baltimore, MD, USA.

Objective(s):
Prior studies have evaluated the outcomes after open (OAR) and Endovascular Thoracoabdominal Aortic Aneurysms (TAAA) repairs. However, little is known about the differences in cost and the potential factors driving these differences. The aim of the study is to evaluate the cost differences of open versus endovascular repairs of intact TAAA, related to in-hospital complications. Methods:
Using the Premier database (2009-2015), we identified all patients with intact TAAA undergoing open and endovascular repair. Chi-square, Student's t-tests and medians test were implemented. Multivariable generalized linear model regression analyses adjusting for age, sex, race, smoking status, Charlson comorbidity index, insurance status, geographic location, and teaching hospital status was used to examine total in-hospital and complications cost. Results:
A total of 879 TAAA repairs were performed [Endovascular: 481(55%) vs. Open: 398(45%)]. Patients undergoing endovascular repair were on average 4 years older ((S.D.): 71.2(10) vs. 66.5(10.9), p<0.001), more likely to be female (48%vs.41%, p=0.009) and hypertensive (87% vs. 80%, p=0.009). Otherwise there were no significant differences in comorbidities between the two groups. Patients undergoing OAR were more likely to stay longer in the hospital [median (IQR): 10(7, 16) vs. 5(2, 9) days, p<0.001]. The median total and fixed cost of OAR was significantly higher compared to endovascular repair ($50,633 vs. $40,991, p<0.001) and ($21,703 vs $13,751, p<0.001), respectively. The in-hospital mortality and complications including cardiac, neurologic, renal, gastrointestinal and pulmonary were all higher following OAR (Figure). Compared to other in-hospital complications, respiratory failure had the highest adjusted additional cost of $20,782 if undergoing endovascular repair whereas neurologic complication had the highest adjusted additional cost of $20,618 after OAR. There was no significant difference in the total adjusted cost attributed to any complication when compared between OAR versus endovascular repair. Furthermore, the overall adjusted total in-hospitalization cost for OAR, irrespective of complications; was $6,202 (95%CI: 2,015-10,389; p=0.004) higher compared to endovascular repair.

Conclusions:
In this large cohort of intact TAAA's, we showed a significantly higher in-hospitalization cost of open compared to endovascular repair despite the additional cost of endografts. This is likely driven by longer length of stay and higher mortality and morbidities following OAR.


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