Treatment decisions for descending thoracic aneurysm: preferences for thoracic endovascular aneurysm repair or surveillance in a discrete choice experiment.
OBJECTIVE
To investigate and rank factors that influence endovascular treatment decisions by specialists for patients with descending thoracic aortic aneurysm (dTAA).


METHODS
Specialists completed a diagrammatic survey describing uncertainty about the benefit of thoracic endovascular aneurysm repair (TEVAR) for dTAA with respect to age, sex, and aneurysm diameter. Subsequently, a detailed discrete choice experiment was designed. Specialists were recruited and asked to indicate treatment their preference (TEVAR or surveillance) in 25 hypothetical cases of dTAA, with variable patient attributes: age, sex, American Society of Anesthesiologists (ASA) grade, aneurysm diameter, adequate landing zone distal to left subclavian artery (LSA), and length of aortic coverage. Data were analysed using multiple logistic regression.


RESULTS
The diagrammatic survey, based on 50 respondents, showed that uncertainty about the benefits of TEVAR was greatest for patients aged 80-85 years (up to 47% of respondents were "unsure") and that uncertainty increased with increasing aneurysm diameter (for an 80-year-old man, 7% were unsure at 5.5 cm and 33% were unsure at 7.0 cm). Seventy-one specialists (mainly from Europe and North America, 86% vascular surgeons and 98% working in units offering TEVAR) completed the discrete choice experiment. Preference for TEVAR increased greatly with enlarging diameter: adjusted odds ratios (OR) >5.5-6.0 cm = 15.8 (95% confidence interval [CI] 9.83-25.40); >6.0-6.5 cm = 393.0 (95% CI 202.00-766.00); >6.5-7.0 cm = 1829.0 (95% CI 400.00-4,181.00). TEVAR was less likely to be preferred in patients older than 75 years (>75-80 years OR 0.32, 95% CI 0.21-0.49; >80-85 years = 0.18, 95% CI 0.11-0.28); in women (OR 0.52, 95% CI 0.37-0.74); in patients classified as ASA grade 4 (OR 0.44, 95% CI 0.36-0.57); and in patients with aorta coverage >25 cm (OR 0.48, 95% CI 0.32-0.74). The proximal landing zone did not influence preference.


CONCLUSIONS
Specialists' preferences for endovascular repair of degenerative dTAA vary widely, and demonstrate clinical uncertainty, especially in octogenarians, and a reluctance to offer TEVAR to women. Aneurysm diameter dominates treatment preferences, but patient fitness and length of aortic coverage (>25 cm) also were influential, although the landing zone distal to LSA was not.
Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London, UK; Division of Surgery, Department of Surgery and Cancer, Imperial College, London, UK. Electronic address: n.rudarakanchana@imperial.ac.uk.
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N
Rudarakanchana
Clinical Trials and Evaluation Unit, British Heart Institute, University of Bristol, Bristol, UK.
B C
BC
Reeves
Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London, UK; Division of Surgery, Department of Surgery and Cancer, Imperial College, London, UK.
C D
CD
Bicknell
Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London, UK.
F M
FM
Heatley
Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London, UK; Division of Surgery, Department of Surgery and Cancer, Imperial College, London, UK.
N J
NJ
Cheshire
Division of Surgery, Department of Surgery and Cancer, Imperial College, London, UK.
J T
JT
Powell
D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D017545:Aortic Aneurysm, Thoracic / Q000175:diagnosis / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects; D057510:Endovascular Procedures / Q000009:adverse effects; D005260:Female; D019538:Health Care Surveys; D054625:Healthcare Disparities; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D018579:Patient Selection; D010818:Practice Patterns, Physicians'; D018570:Risk Assessment; D012307:Risk Factors; D012737:Sex Factors; D011795:Surveys and Questionnaires; D013997:Time Factors; D016896:Treatment Outcome; D035501:Uncertainty; D057832:Watchful Waiting
Discrete choice experiment; Endovascular procedures; Professional preferences; Thoracic aortic aneurysm; Treatment variation