title: Management of diseases of the descending thoracic aorta in the endovascular era: a Medicare population study.
abstract: OBJECTIVE
  Prospective trials have shown improved perioperative outcomes with endovascular repair of thoracic aortic (TEVAR) pathologies compared with conventional surgery (OPEN). There are no long-term population data detailing the impact of TEVAR on practice patterns and results of treatment of descending thoracic aortic pathology (DTA), which are the goal of this study.
  
  
  METHODS
  All procedures performed on the DTA captured in the Medicare database from 2004 to 2007 were identified by ICD-9 codes and stratified into OPEN and TEVAR cohorts. Outcomes included perioperative mortality (χ(2)) and 5-year actuarial survival.
  
  
  RESULTS
  There were 11,166 patients identified (4838 [43%] TEVAR vs. 6328 [57%] OPEN) with 7247 (65%) nonruptured, degenerative thoracic aortic aneurysms (TAA), 2701 (24%) descending aortic dissections, 1033 (9%) thoracic aortic ruptures, and 185 (2%) traumatic aortic tears. The distribution of cases changed significantly during the study period (P < 0.0001) with an increase in TEVAR, decrease in OPEN, and increase in total cases over time (). The perioperative mortality was lower in the TEVAR group for the entire population (360 [7.4%] TEVAR vs. 1175 [18.5%] OPEN, P < 0.0001), and for the individual pathologies: TAA (182/3529 [5%] TEVAR vs. 451/3718 [12%] OPEN, P < 0.001), dissections (76/833 [9%] TEVAR vs. 399/1868 [21%] OPEN, P < 0.001) and ruptures (87/368 [24%] TEVAR vs. 298/665 [45%] OPEN, P < 0.0001). The Kaplan-Meier curve significantly favored TEVAR for the entire cohort because of the early mortality of the OPEN cohort but the curves converged by 5 years. The 5-year survival by indication was: entire population (53.4% TEVAR vs. 53.3% OPEN, P < 0.0001), TAA (55.8% TEVAR vs. 59.7% OPEN, P = 0.84), dissection (58.2% TEVAR vs. 50.6% OPEN, P < 0.0001), ruptures (23.3% TEVAR vs. 25.3% OPEN, P = 0.001), and trauma (62.9% TEVAR vs. 50.9% OPEN, P = 0.12).
  
  
  CONCLUSIONS
  There has been a significant increase in the use of TEVAR for management of diseases of the DTA. TEVAR offers a significant perioperative survival advantage when compared with OPEN regardless of the indication for repair. However, in the Medicare population, the 5-year survival is similar between the 2 cohorts.
authors.affiliation: Division of Vascular and Endovascular Surgery of the General Surgical Services, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA. mconrad@partners.org
authors.forename: Mark F
authors.initials: MF
authors.lastname: Conrad
authors.forename: Emel A
authors.initials: EA
authors.lastname: Ergul
authors.forename: Virendra I
authors.initials: VI
authors.lastname: Patel
authors.forename: Vikram
authors.initials: V
authors.lastname: Paruchuri
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Kwolek
authors.forename: Richard P
authors.initials: RP
authors.lastname: Cambria
mesh_terms: D000368:Aged; D000784:Aortic Dissection / Q000401:mortality / Q000601:surgery; D001013:Aorta, Thoracic / Q000293:injuries; D017545:Aortic Aneurysm, Thoracic / Q000191:economics / Q000401:mortality / Q000601:surgery*; D001019:Aortic Rupture / Q000401:mortality / Q000601:surgery; D005260:Female; D006801:Humans; D008297:Male; D006278:Medicare; D015996:Survival Rate; D014481:United States; D014656:Vascular Surgical Procedures