Outcomes and cost of open versus endovascular repair of intact thoracoabdominal aortic aneurysm

Objective: Many previous studies have evaluated the outcomes of open and endovascular repair of thoracoabdominal aortic aneurysms (TAAAs). However, little is known about the differences in cost of these procedures and the potential factors driving these differences. The aim of this study was to evaluate the outcomes and cost of open aortic repair (OAR) vs endovascular repair of intact TAAA. Methods: All patients undergoing repair for intact TAAA were identified in the Premier Healthcare Database (July 2009-March 2015). Categorical and continuous variables were analyzed using the chi(2) test, Student t-test, and median test as appropriate. A multivariable generalized linear model was used to examine total in-hospital cost. Results: A total of 879 TAAA repairs were identified (481 [55%) endovascular repairs vs 398 [45%] OARs). Patients undergoing endovascular repair were on average 5 years older (71.2 [+/-10.0] years vs 66.5 [+/-10.9] years; P < .001) and more likely to be female (48% vs 42%; P = .05) and hypertensive (87% vs 80%; P = .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 [interquartile range], 11 [7-20] days vs 5 [2-9] days; P < .001). In-hospital mortality (15% vs 5%; P < .001) and all major complications were two to three times higher after OAR. The median total cost of OAR was significantly higher compared with endovascular repair (cost [interquartile range], $44,355 [$32,177-$54,824] vs $36,612 [$24,395-$53,554]; P = .004). The majority of the cost attributed to TAAA repair was also higher in patients undergoing open repair: room and board ($11,561 vs $4720), operating room ($9230 vs $4929), pharmacy ($2309 vs $900), blood bank ($1189 vs $195), rehabilitation/physical therapy ($378 vs $236), and respiratory therapy ($875 vs $168; all P < .001). Only the cost of central supplies, which includes endovascular grafts and stents, was the highest among patients undergoing endovascular repair ($17,472 vs $5501; P < .001). The cost of diagnostic imaging ($625 vs $595) and anesthesia ($479 vs $478) was similar in both approaches. In a multivariable analysis, the adjusted total hospitalization cost for OAR was $5974 (95% confidence interval, $1828-$10,120; P = .005) higher compared with endovascular repair. However, after adjusting for in-hospital complications, no difference was seen between the two approaches (-$460; 95% confidence interval, -$4390 to $3470; P = .82). Conclusions: In this large cohort of intact TAAAs, we showed a significantly higher adjusted total hospitalization cost of open compared with endovascular repair despite the additional cost of endografts. This is likely driven by longer length of stay and higher morbidity after OAR.