title: Survival after open versus endovascular thoracic aortic aneurysm repair in an observational study of the Medicare population.
abstract: BACKGROUND
  The goal of this study was to describe short- and long-term survival of patients with descending thoracic aortic aneurysms (TAAs) after open and endovascular repair (TEVAR).
  
  
  RESULTS
  Using Medicare claims from 1998 to 2007, we analyzed patients who underwent repair of intact and ruptured TAA, identified from a combination of procedural and diagnostic International Classification of Disease, ninth revision, codes. Our main outcome measure was mortality, defined as perioperative mortality (death occurring before hospital discharge or within 30 days), and 5-year survival, from life-table analysis. We examined outcomes across repair type (open repair or TEVAR) in crude, adjusted (for age, sex, race, procedure year, and Charlson comorbidity score), and propensity-matched cohorts. Overall, we studied 12 573 Medicare patients who underwent open repair and 2732 patients who underwent TEVAR. Perioperative mortality was lower in patients undergoing TEVAR compared with open repair for both intact (6.1% versus 7.1%; P=0.07) and ruptured (28% versus 46%; P<0.0001) TAA. However, patients with intact TAA selected for TEVAR had significantly worse survival than open patients at 1 year (87% for open, 82% for TEVAR; P=0.001) and 5 years (72% for open; 62% for TEVAR; P=0.001). Furthermore, in adjusted and propensity-matched cohorts, patients selected for TEVAR had worse 5-year survival than patients selected for open repair.
  
  
  CONCLUSIONS
  Although perioperative mortality is lower with TEVAR, Medicare patients selected for TEVAR have worse long-term survival than patients selected for open repair. The results of this observational study suggest that higher-risk patients are being offered TEVAR and that some do not benefit on the basis of long-term survival. Future work is needed to identify TEVAR candidates unlikely to benefit from repair.
authors: Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03766, USA. philip.goodney@hitchcock.org
authors: Philip P
authors: PP
authors: Goodney
authors: Lori
authors: L
authors: Travis
authors: F Lee
authors: FL
authors: Lucas
authors: Mark F
authors: MF
authors: Fillinger
authors: David C
authors: DC
authors: Goodman
authors: Jack L
authors: JL
authors: Cronenwett
authors: David H
authors: DH
authors: Stone
mesh_terms: D000368:Aged; D017545:Aortic Aneurysm, Thoracic / Q000453:epidemiology / Q000401:mortality* / Q000628:therapy*; D015331:Cohort Studies; D057510:Endovascular Procedures / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008137:Longitudinal Studies; D008297:Male; D006278:Medicare; D012189:Retrospective Studies; D012307:Risk Factors; D015996:Survival Rate; D016896:Treatment Outcome; D014481:United States; D014486:United States Food and Drug Administration; D014656:Vascular Surgical Procedures / Q000379:methods*