P Narayan, A Wong, I Davies, A J Bryan, P Wilde, G J Murphy Does TEVAR provide a financial benefit...
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Transcript of P Narayan, A Wong, I Davies, A J Bryan, P Wilde, G J Murphy Does TEVAR provide a financial benefit...
P Narayan, A Wong, I Davies, A J Bryan, P Wilde, G J Murphy
Does TEVAR provide a financial benefit for management of descending thoracic aortic
pathologies?
Background Management of descending aortic pathology is a
complex and challenging area
Surgical management is indicated in specific situations
Endo-Vascular Surgical Repair [TEVAR] provides another important option
Aim To assess early and mid term outcomes of TEVAR
compared with surgical repair
To compare the financial implications of TEVAR and surgical management
Methods Retrospective study
Time period: April 1996- February 2009
85 procedures
Surgical repair: 35
TEVAR: 49
Data accessed from computerised database –PATS System
and validated by case note reviews
Hospital costs calculated from NHS reference costs for staff time,
consumables, transfusion and length of stay.
Statistical Analysis
Data tabulated as N(%) for categorical data and median (inter-
quartile range) for continuous data
Continuous variables analysed with Mann Whitney U test
Categorical variables analysed with Fisher’s exact test or Chi-
square
Kaplan-Meier estimates were used to compare re- intervention
and survival
Trends in the Management of Descending Thoracic Aortic Pathology
Patient CharacteristicsSurgery (n=35) TEVAR (n=49) P value
Age (years) 55.5(33-67.5) 57.5(40.25-72) 0.210
Male 29 (81%) 34 (69%) 0.245
Pre op Neurological dysfunction
1(2%) 2(4%) 0.625
Previous cardiac surgery 10(27%) 12(24%) 0.818
COAD 3(8%) 4(8%) 0.607
Pre-op Renal Impairment 2(5%) 6(12%) 0.270
Current Smoker 20(55%) 23(47%) 0.356
Marfan 1(2%) 3(6%) 0.432
Diabetes 1(2%) 1(2%) 0.683
Hypertension 19(53%) 23(47%) 0.595
EuroScore 10(7-10) 9(8-10) 0.562
Emergency 12 (33%) 21 (43%) 0.047
Critical Preoperative State 12 (34%) 16 (33%) 0.876
Procedural Characteristics
Surgery TEVAR p value
Operative Sessions 2 (2.0-2.3) 1 (1-1) <0.0001
Aneurysm 19 (53%) 22 (45%) 0.473
Thoracoabdominal 7 (19%) 5 (10%) 0.148
Arch 5 (14%) 0 0.011
Dissection 10 (28%) 17(35%) 0.499
Acute 5 (14%) 16 (33%) 0.047
Chronic 5 (14%) 1 (2%) 0.047
Trauma 5 (14%) 7 (14%) 0.303
Other 2 (5%) 3 (6%) 0.707
RBC Transfusion 8(3-12) 0(0-3) <0.0001
Platelet Transfusion 2(0-3) 0(0-0) <0.0001
FFP Transfusion 2(0-8) 0(0-0) <0.0001
In Hospital Clinical OutcomeSurgery (n=35) TEVAR(n=49) P value
Atrial Fibrillation 12(33%) 1(2%) <0.0001
Inotropic Support 17(47%) 1(2%) <0.001
Neurological Complication 9(25%) 6(12%) 0.244
Renal Complication 11(31%) 5(10%) 0.025
GI Complication 5(14%) 5(10%) 0.513
Chest Infection 9(25%) 1(2%) 0.001
ARDS 2(5%) 0(0%) 0.159
Re-intubation 5(14%) 3(6%) 0.253
Tracheostomy 8(22%) 2(4%) 0.020
ITU Stay 6(3-11) 1(1-4) <0.0001
Hospital Stay 16(9-26) 10(6-17) 0.022
In Hospital Death 7(20%) 3(6%) 0.03
Hospitalisation Costs of EVAR versus Surgery
Cost Surgery (£) TEVAR(£) p value
Staff Costs 1836 (1836-2075) 1433 (1433-1433) <0.0001
Consumable/ Stent Costs 412 (216-696) 8000 (8000-10000) <0.0001
Procedure Cost 2468 (2260-3168) 9581 (9581-11581) <0.0001
Transfusion Costs 1327 (531-2124) 0 (0-531) <0.0001
ICU Costs 7200 (3600-13200) 2400 (1200-6000) <0.0001
Hospitalisation Cost 10400 (5238-22500) 5350 (3200-8150) 0.001
Total Cost 15045 (9299-27571) 16694 (13532-21729) 0.414
Mid-term Follow-up
Surgery (n=35) TEVAR (n=49)
Reintervention 1 (3%) 9 (18%)
Death 11 (31%) 10(20%)
Death or Reintervention
11 (31%) 18 (37%)
Mid-term Outcomes of TEVAR and Surgery for Diseases of the Descending Thoracic Aorta
Surgery
TEVAR
Surgery
TEVAR
Mortality Re-intervention
Log Rank p=0.002Log Rank p=0.901
Conclusions
TEVAR is associated with superior short-term results
Mid term survival is similar to surgery
Re-intervention rate is significantly higher in TEVAR
Resource utilisation is similar in both groups for the primary procedure
Costs may prove to be higher in the TEVAR group with re-interventions