Budget Impact of Percutaneous Endovascular Abdominal Aorta Aneurysm Repair (PEVAR) Compared to Standard Endovascular Repair in Canadian Hospitals

Autor: Graham Roche-Nagle, Maureen Hazel, Dheeraj K. Rajan
Rok vydání: 2015
Předmět:
Zdroj: Journal of Vascular Surgery. 62:1373
ISSN: 0741-5214
DOI: 10.1016/j.jvs.2015.08.014
Popis: s from the 2015 Canadian Society for Vascular Surgery Annual Meeting In Situ Laser Fenestration During TEVAR: Innovation in Practice Jean M. Panneton, MD, S. Sadie Ahanchi, MD, Jason Moore, MD. Division of Vascular Surgery, Eastern Virginia Medical School, Norfolk, Va Objectives: Retrograde in situ laser fenestration of arch branches during emergency thoracic endovascular aortic repair (TEVAR) is an innovative method to revascularize aortic branches for a variety of acute thoracic aortic pathology. Methods: We reviewed all consecutive patients who underwent TEVAR with left subclavian artery (LSA) or left carotid artery (LCA) revascularization by in situ laser graft fenestration from September 2009 through October 2013. Results: Emergency TEVAR with laser fenestration was successfully performed in 35 patients for all types of thoracic aortic pathology, including seven ruptures. An average of two endografts (range, 1-4) were deployed in zones 0, 1, and 2. Thirty-four LSA and one LCA were revascularized with a balloon-expandable covered stent. Mean operative time was 162 minutes. Average hospital length of stay was 12 days. No major fenestration-related complications occurred. Stroke rate was 2.9% (1 of 35). A stroke occurred in a patient with a previous stroke presenting with hypotension from a ruptured intramural hematoma. One patient developed postoperative paraplegia from a ruptured acute type B dissection. The in-hospital operative mortality was 5.7%. Mean imaging follow-up by computed tomography angiography (CTA) was 20 months (range, 1-53 months) and demonstrated a 100% primary patency for all stented branches. Two patients had asymptomatic LSA stent stenosis. Mean clinical follow-up was 23 months (range, 1-66 months). The fenestration-related reintervention rate was 8.6% and all three were type Ic endoleaks (1 early requiring coiling and 2 late requiring restenting of the LSA). There was no instance of type III endoleak between the stented branch and the endograft. The aortic reintervention rate was 5.7%, and both patients had type Ia endoleaks unrelated to the fenestration. Conclusions: In situ retrograde laser fenestration can safely and effectively revascularize arch branches during TEVAR. Imaging surveillance by CTA has documented the durability of this innovative technique of intraoperative endograft modification. Author Disclosures: J. Panneton: None; S. Ahanchi: None; J. Moore: None. Budget Impact of Percutaneous Endovascular Abdominal Aorta Aneurysm Repair (PEVAR) Compared to Standard Endovascular Repair in Canadian Hospitals Graham Roche-Nagle, Maureen Hazel, Dheeraj K. Rajan. Division of Vascular Surgery, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada; Johnson & Johnson Medical Companies, Markham, Ontario, Canada; Division of Vascular and Interventional Radiology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada Objectives: The percutaneous endovascular abdominal aortic repair (PEVAR) approach is a minimally invasive technique that has demonstrated clinical benefit over traditional surgical cutdown associated with standard endovascular abdominal aortic aneurysm (AAA) repair (EVAR) yet has not realized wide-spread adoption. The objective of our study was to evaluate the budget impact to a hospital of changing the technique for AAA repair from the EVAR approach to the PEVAR approach. Methods: We examined the budget impact of replacing the EVAR approach with the PEVAR approach in a Canadian hospital that performs 100 EVARs annually. The model incorporated the costs associated with surgery, length of stay, and postoperative complications occurring #30 days. The cost data used in the model were obtained from peer reviewed literature, the Ontario Case Costing Initiative, and case costing from a large Canadian hospital. Patient outcomes data were obtained from pooling published prospective studies after completing a comprehensive literature review. A multivariate sensitivity analysis was completed. Results: The use of PEVAR in AAA repair is associated with increased access device costs compared with the EVAR approach ($1000 vs $400). However, AAA repair completed with the PEVAR approach demonstrates reduced operating time (101 vs 133 minutes), a reduction in length of stay (2.2 vs 3.5 days), time in the recovery room (174 vs 193 minutes), and in postoperative complications (6% vs 30%), which offset the increased device costs. The model establishes that switching to the PEVAR approach in a Canadian hospital performing 100 AAA repairs annually would result in a potential cost avoidance of $245,120 (Fig). Conclusions: A change in AAA repair technique from EVAR to PEVAR can be a cost-effective solution for Canadian hospitals. Fig. Hospital budget impact of conversion from EVAR to PEVAR. Author Disclosures: G. Roche-Nagle: ProctordCook Canada and Cordis; proctor/consultantdCordis; M. Hazel: None; D. Rajan: None. Short-Term Outcomes of Introducing Percutaneous Endovascular Aneurysm Repair in Comparison to Open Endovascular Aneurysm Repair At an Academic Institution Beverley Chan, Varun Srivatsav, Fadi Elias, Tara Adrinopoulos, David Szalay, John Harlock, Theodore Rapanos. McMaster University, Hamilton, Ontario, Canada; Hamilton Health Sciences, Hamilton, Ontario, Canada Objectives: Percutaneous endovascular aneurysm repairs (PEVARs) were introduced at the Hamilton General Hospital in April 2011. This study was conducted to demonstrate the short-term 30-day outcomes for elective PEVARs compared with elective open EVARs (OEVARs) at a single institution. Methods: A retrospective record review on elective abdominal aneurysm repairs performed from April 2011 to December 2012 at Hamilton General Hospital was performed. Thirty-day outcomes were recorded. Results: Four of five vascular surgeons adopted using PEVARs over the time period, during which 26 PEVARs and 107 OEVARs for elective abdominal aneurysm cases were performed. Two PEVARs were converted to OEVARs. There was one death (3.8%) in the PEVAR group and one death in the OEVAR group (0.9%). Postoperative complications were slightly higher in the OEVAR group than in the PEVAR group but not statistically significant, with more wound infections (4.7% vs 0%), myocardial infarction (0.9% vs 0%), venous thromboembolic events (4.7% vs 0%), and respiratory events (4.7% vs 0%). Mean length of stay was similar at 1 day in the OEVAR group (range, 1-24 days) and in the PEVAR group (range, 1-9 days). Nine percent of the OEVAR group and 7.6% of the PEVAR group were readmitted in the first 30 days. In the OEVAR group, five patients (4.7%) had to return to the operating room in the first 30 days vs one patient (3.8%) in the PEVAR group. Conclusions: We have demonstrated the safety and efficacy of introducing PEVARs at an academic hospital that is comparable to OEVARs.
Databáze: OpenAIRE
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