1. P Narayan, A Wong, I Davies, A J Bryan, P Wilde, G J Murphy Does TEVAR provide a financial benefit for management of descending thoracic aortic pathologies?

2. Background  Management of descending aortic pathology is a complex and challenging area  Surgical management is indicated in specific situations  Endo-Vascular Surgical Repair [TEVAR] provides another important option Aim  To assess early and mid term outcomes of TEVAR compared with surgical repair  To compare the financial implications of TEVAR and surgical management

3. Methods  Retrospective study  Time period: April 1996- February 2009  85 procedures Surgical repair: 35 TEVAR: 49  Data accessed from computerised database –PATS System and validated by case note reviews  Hospital costs calculated from NHS reference costs for staff time, consumables, transfusion and length of stay.

4. Statistical Analysis  Data tabulated as N(%) for categorical data and median (inter- quartile range) for continuous data  Continuous variables analysed with Mann Whitney U test  Categorical variables analysed with Fisher’s exact test or Chi- square  Kaplan-Meier estimates were used to compare re- intervention and survival

5. Trends in the Management of Descending Thoracic Aortic Pathology

6. Patient Characteristics Surgery (n=35)TEVAR (n=49)P value Age (years) 55.5(33-67.5)57.5(40.25-72)0.210 Male 29 (81%)34 (69%)0.245 Pre op Neurological dysfunction 1(2%)2(4%)0.625 Previous cardiac surgery 10(27%)12(24%)0.818 COAD 3(8%)4(8%)0.607 Pre-op Renal Impairment 2(5%)6(12%)0.270 Current Smoker 20(55%)23(47%)0.356 Marfan 1(2%)3(6%)0.432 Diabetes 1(2%) 0.683 Hypertension 19(53%)23(47%)0.595 EuroScore 10(7-10)9(8-10)0.562 Emergency 12 (33%)21 (43%)0.047 Critical Preoperative State 12 (34%)16 (33%)0.876

7. Procedural Characteristics SurgeryTEVARp value Operative Sessions 2 (2.0-2.3)1 (1-1)<0.0001 Aneurysm 19 (53%)22 (45%)0.473 Thoracoabdominal 7 (19%)5 (10%)0.148 Arch 5 (14%)00.011 Dissection 10 (28%)17(35%)0.499 Acute 5 (14%)16 (33%)0.047 Chronic 5 (14%)1 (2%)0.047 Trauma 5 (14%)7 (14%)0.303 Other 2 (5%)3 (6%)0.707 RBC Transfusion 8(3-12)0(0-3)<0.0001 Platelet Transfusion 2(0-3)0(0-0)<0.0001 FFP Transfusion 2(0-8)0(0-0)<0.0001

8. In Hospital Clinical Outcome Surgery (n=35)TEVAR(n=49)P value Atrial Fibrillation12(33%)1(2%) <0.0001 Inotropic Support17(47%)1(2%) <0.001 Neurological Complication9(25%)6(12%)0.244 Renal Complication11(31%)5(10%)0.025 GI Complication5(14%)5(10%)0.513 Chest Infection9(25%)1(2%)0.001 ARDS2(5%)0(0%)0.159 Re-intubation5(14%)3(6%)0.253 Tracheostomy8(22%)2(4%)0.020 ITU Stay6(3-11)1(1-4)<0.0001 Hospital Stay16(9-26)10(6-17)0.022 In Hospital Death7(20%)3(6%)0.03

9. Hospitalisation Costs of EVAR versus Surgery CostSurgery (£)TEVAR(£)p value Staff Costs 1836 (1836-2075)1433 (1433-1433) <0.0001 Consumable/ Stent Costs 412 (216-696)8000 (8000-10000) <0.0001 Procedure Cost 2468 (2260-3168)9581 (9581-11581) <0.0001 Transfusion Costs 1327 (531-2124)0 (0-531) <0.0001 ICU Costs 7200 (3600-13200)2400 (1200-6000) <0.0001 Hospitalisation Cost 10400 (5238-22500)5350 (3200-8150) 0.001 Total Cost 15045 (9299-27571)16694 (13532-21729) 0.414

10. Mid-term Follow-up Surgery (n=35)TEVAR (n=49) Reintervention1 (3%)9 (18%) Death11 (31%)10(20%) Death or Reintervention 11 (31%)18 (37%)

11. Mid-term Outcomes of TEVAR and Surgery for Diseases of the Descending Thoracic Aorta Surgery TEVAR Surgery TEVAR Mortality Re-intervention Log Rank p=0.002 Log Rank p=0.901

12. Conclusions  TEVAR is associated with superior short-term results  Mid term survival is similar to surgery  Re-intervention rate is significantly higher in TEVAR  Resource utilisation is similar in both groups for the primary procedure  Costs may prove to be higher in the TEVAR group with re-interventions