Influence of Hospital Volume on Outcomes of Thoracic Endovascular Repair in Vascular Quality Initiative Database: 5-year National Study. Presenting Author:

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KAREN L. WALKER MS JONATHAN J. SHUSTER PHD THOMAS M. BEAVER MD, MPH DIVISION OF THORACIC AND CARDIOVASCULAR SURGERY DIVISION OF BIOSTATISTICS UNIVERSITY.

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Presentation transcript:

Influence of Hospital Volume on Outcomes of Thoracic Endovascular Repair in Vascular Quality Initiative Database: 5-year National Study. Presenting Author: Satinderjit (Vinny) Locham, MD Post-Doctoral Research Fellow University of California San Diego Senior Author: Mahmoud Malas, MD MHS RPVI FACS Professor In Residence Chief Division of Vascular and Endovascular Surgery UCSD, Health System

Disclosures: None

Background: Gore TAG was the first commercially available thoracic endografts introduced in 2005. Since then, multiple devices have been approved. Original Gore TAG Conformable Gore TAG Bolton RelayPlus Valiant Zenith Alpha

Background: Relationship between hospital volume and outcomes in AAA repair have been well described. However, very few studies are available on TEVAR.

1,838 patients

From 2005-2007, patients treated at HVH (>17 per year) From 2005-2007, patients treated at HVH (>17 per year) Since 2011, 53% have undergone TEVAR by low volume surgeons

Medicare claims (1999-2007). 12,573 open and 2,732 TEVAR

Aim of the study: To use a large national vascular database and look at the influence of hospital volume and outcomes in patients undergoing TEVAR.

Methods: Inclusion: Exclusion: All patients undergoing TEVAR (2014-2018). Exclusion: Distal extent (zone >6). PAU/Hematoma/thrombus

Methods: Hospital volumes (Low vs. High) Total mean number of cases per year at each center. Grouped them into two quintiles. Stratified by symptomatic status. Asymptomatic vs. Symptomatic/Rupture. Statistical analysis: Univariate: Student t-test, median, chi-square. Multivariable logistic regression analysis.

Results: N=2,639 Centers - 133 Asymp. N=1,363 (52%) LVH (54%) HVH (46%) Symp. N=1,276 (48%) LVH (47%) HVH (53%)

Results: Trends

Results: Demographics Asymptomatic Symptomatic/Rupture Low High P-value 741 (54.4%) 622 (45.6%) 598 (46.9%) 678 (53.1%) Mean number of cases, SD 4.80 (1.95) 19.22 (13.33) 5.12 (2.03) 20.01 (12.56) Demographics Age, median (IQR) 72 (63,78) 70 (61,77) 0.10 63 (47,75) 64 (49,75) 0.73 Male 455 (61.4) 367 (59.0) 0.37 359 (60.0) 418 (61.7) 0.55 Race 0.06 0.81 White 565 (76.3) 476 (76.5) 364 (60.9) 410 (60.5) Black 108 (14.6) 108 (17.4) 160 (26.8) 176 (26.0) Others 69 (9.2) 38 (6.1) 74 (12.4) 92 (13.6)

Results: Comorbidities Asymptomatic Symptomatic/Rupture Low High P-value Hx CAD 144 (19.5) 104 (16.7) 0.19 88 (14.8) 90 (13.3) 0.45 Hx CHF 102 (13.8) 66 (10.6) 0.08 60 (10.1) 60 (8.9) 0.46 Hx COPD 232 (31.4) 185 (29.7) 0.51 118 (19.8) 141 (20.9) 0.65 Hx DM 133 (18.0) 95 (15.3) 0.18 75 (12.6) 95 (14.1) Hx Dialysis 16 (2.2) 20 (3.2) 0.23 20 (3.4) 15 (2.2) 0.22 HTN 621 (83.9) 522 (83.9) 0.99 430 (72.2) 498 (73.7) 0.54 Smoker 544 ( 73.5) 464 (75.0) 375 (63.3) 416 (61.7) 0.55 Hx PCI/CABG 150 (20.3) 128 (20.6) 0.89 79 (13.3) 97 (14.4) 0.58 Hx CEA/CAS 28 (3.8) 16 (2.6) 0.21 12 (2.0) 14 (2.1) 0.95 Aneurysm repair 236 (31.9) 188 (30.2) 98 (16.5) 111 (16.4) 0.98 PVI/Bypass 81 (11.0) 88 (14.2) 0.07 33 (5.6) 67 (9.9) 0.004 Major amputation 6 (0.8) 3 (0.5) 2 (0.3)

Results: Operative characteristics Asymptomatic Symptomatic/Rupture Low High P-value Urgency 0.36 0.16 Elective 648 (87.5) 554 (89.1) 223 (37.3) 279 (41.2) Urgent/Emergent 93 (12.6) 68 (10.9) 375 (62.7) 399 (58.9) Contrast, mean (S.D.) 103.91 (66.30) 103.64 (68.33) 0.94 97.75 (65.14) 91.66 (58.85) 0.09 Crystalloid in liters 1.69 (1.09) 1.74 (1.07) 0.53 1.68 (1.17) 1.72 (1.23) 0.6 EBL, mean (S.D.) 311.13 (822.63) 227.48 (333.78) 0.02 244.47 (475.95) 188.63 (319.55) Flurotime, mean (S.D.) 18.34 (18.44) 17.19 (16.94) 0.26 14.38 (13.48) 13.53 (12.98) 0.27 Total procedure time 140.41 (98.91) 135.45 (81.13) 0.32 142.75 (115.00) 125.52 (85.94) 0.002 Intraoperative transfusion 120 (16.3) 100 (16.1) 0.93 147 (24.7) 187 (27.6) 0.24 IVUS/TEE use 262 (35.6) 278 (44.9) <0.001 319 (54.1) 418 (61.7) 0.006 Conversion to open repair 4 (0.5) 4 (0.6) 0.8 4 (0.7) 5 (0.6) 0.86

Results: Operative characteristics Asymptomatic Symptomatic/Rupture Low High P-value Spinal drain placement <0.001 0.004 None 403 (54.5) 273 (43.9) 189 (31.7) 264 (56.7) Preop/postop 336 (45.5) 349 (56.1) 211 (35.4) 293 (43.3) Custom modified grafts 17 (2.3) 5 (0.8) 0.03 17 (2.9) 5 (0.7) Branch Staged Procedure 86 (31.4) 120 (40.4) 44 (18.3) 92 (26.8) 0.02 Proximal Zone 0.005 Zone 0,1,2 157 (21.9) 200 (32.2) 151 (25.3) 228 (33.6) Zone 3 302 (40.8) 254 (40.8) 318 (53.2) 322 (47.5) Zone 4,5 282 (38.1) 168 (27.0) 129 (21.6) 128 (18.9)

Results: Outcomes

Results: Logistic regression. HVH (Ref) vs. LVH Asymptomatic Symptomatic/Rupture OR (95% CI) P-Value 30-day mortality 1.15 (0.55-2.40) 0.72 0.94 (0.52-1.70) 0.84 Renal 0.88 (0.44-1.77) 2.21 (1.09-4.51) 0.03 Neuro 0.86 (0.50-1.49) 0.60 0.93 (0.57-1.51) 0.77 Cardiac 1.26 (0.82-1.94) 0.29 1.01 (0.72-1.42) 0.96 Pulmonary 1.12 (0.65-1.93) 0.68 1.02 (0.60-1.74) 0.95 Adjusted for age, gender, coronary disease, urgency (elective vs emergent/urgent), indication (trauma vs. dissection vs. aneurysm), blood loss, and proximal zone of the disease (zone 0-2 vs. zone 3 vs. zone4).

Conclusion: Increased in number of TEVARs performed at LVH. HVHs operate on more complex patients (higher thoracic zones [0-2]). 30-day mortality independent of hospital volume. Long-term studies on durability and re-interventions are needed.

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