Johns Hopkins Bayview Vascular and Endovascular Clinical Research Center, Baltimore, Md.
Johns Hopkins Bayview Vascular and Endovascular Clinical Research Center, Baltimore, Md.
J Vasc Surg. 2019 Apr;69(4):1036-1044.e1. doi: 10.1016/j.jvs.2018.06.211. Epub 2018 Oct 3.
Fenestrated endovascular aneurysm repair (FEVAR) has expanded the indications of this minimally invasive procedure to include patients with pararenal aneurysms. The actual cost of this relatively newer technology compared with standard endovascular aneurysm repair (EVAR) has not been studied before. Thus, the aim of this study was to analyze in-hospital costs and adverse outcomes in patients undergoing FEVAR vs EVAR for intact abdominal aortic aneurysms (AAAs).
Using the Premier Healthcare Database (2012-2015), we identified all patients who underwent elective EVAR and FEVAR. Univariable (χ test, Student t-test, median test) and multivariable (logistic regression and generalized linear modeling) analyses were implemented to examine in-hospital cost and adverse outcomes adjusting for patients' demographics, comorbidities, and regional characteristics.
A total of 17,689 elective endovascular AAA repairs were performed; 1641 patients underwent FEVAR (9%), and the remaining 16,048 patients underwent standard EVAR (91%). Patients undergoing FEVAR were more likely to be white (86.3% vs 84.3%; P = .03). Both groups had similar comorbidities except for cerebrovascular disease, which was higher among patients undergoing FEVAR (8.4% vs 6.7%; P = .01). The total length of hospital stay was slightly higher in patients undergoing FEVAR compared with EVAR (mean [standard deviation], 2.40 [3.39] days vs 2.23 [3.10] days; P = .03). The rates of any complication (11.3% vs 9.6%), renal injury (5.8% vs 4.3%), and neurologic injury (0.7% vs 0.4%) were significantly higher in the FEVAR group (all P < .05). No differences were seen in mortality (0.8% vs 0.5%) or cardiac (4.9% vs 4.4%), pulmonary (2.4% vs 2.2%), and bowel (1.5% vs 1.2%) complications between the two groups (all P > .05). In multivariable logistic regression analysis, FEVAR was associated with 40% increased odds of renal failure (odds ratio, 1.40; 95% confidence interval [CI], 1.11-1.76; P = .004) and 91% increased odds of neurologic injury (odds ratio, 1.91; 95% CI, 1.02-3.57; P = .04). The median total cost of the treatment was also significantly higher among patients undergoing FEVAR ($28,227 vs $26,781; P < .001). After adjustment, generalized linear modeling analysis showed that the cost of FEVAR was on average $1612 higher than the cost of EVAR (adjusted cost, $1612; 95% CI, $1123-$2101; P < .001).
In this large cohort of elective endovascular AAA repairs, compared with standard EVAR, FEVAR is associated with significantly increased odds of renal and neurologic injury. In addition, despite adjusting for patients' demographics, comorbidities, and major complications, total cost of FEVAR was significantly higher compared with standard EVAR. This is likely driven by the additional cost of fenestrated endografts and by the increased rate of complications related to FEVAR.
开窗式血管内动脉瘤修复术（FEVAR）将这一微创技术的适应证扩大到了包括肾周动脉瘤的患者。与标准血管内动脉瘤修复术（EVAR）相比，这种相对较新的技术的实际成本尚未进行过研究。因此，本研究旨在分析接受 FEVAR 与 EVAR 治疗的完整腹主动脉瘤（AAA）患者的住院费用和不良结局。
使用 Premier Healthcare Database（2012-2015 年），我们确定了所有接受择期 EVAR 和 FEVAR 的患者。使用单变量（卡方检验、学生 t 检验、中位数检验）和多变量（logistic 回归和广义线性模型）分析来检查住院费用和不良结局，同时调整患者的人口统计学、合并症和区域特征。
共进行了 17689 例择期血管内 AAA 修复术；1641 例患者接受了 FEVAR（9%），其余 16048 例患者接受了标准 EVAR（91%）。接受 FEVAR 的患者更有可能是白人（86.3%比 84.3%；P=0.03）。两组的合并症相似，除了脑血管疾病，接受 FEVAR 的患者更高（8.4%比 6.7%；P=0.01）。与 EVAR 相比，接受 FEVAR 的患者的总住院时间略长（平均[标准差]，2.40[3.39]天比 2.23[3.10]天；P=0.03）。FEVAR 组的任何并发症（11.3%比 9.6%）、肾损伤（5.8%比 4.3%）和神经损伤（0.7%比 0.4%）的发生率显著更高（所有 P<0.05）。两组之间的死亡率（0.8%比 0.5%）或心脏（4.9%比 4.4%）、肺部（2.4%比 2.2%）和肠道（1.5%比 1.2%）并发症发生率无差异（所有 P>0.05）。多变量 logistic 回归分析显示，FEVAR 与肾衰竭的几率增加 40%相关（比值比，1.40；95%置信区间[CI]，1.11-1.76；P=0.004），与神经损伤的几率增加 91%相关（比值比，1.91；95%CI，1.02-3.57；P=0.04）。接受 FEVAR 的患者的治疗总成本中位数也明显更高（$28227 比 $26781；P<0.001）。经过调整，广义线性模型分析显示，FEVAR 的费用比 EVAR 平均高出 1612 美元（调整后的费用，$1612；95%CI，$1123-$2101；P<0.001）。
在这项大型择期血管内 AAA 修复术患者队列中，与标准 EVAR 相比，FEVAR 与肾和神经损伤的几率显著增加相关。此外，尽管调整了患者的人口统计学、合并症和主要并发症，但 FEVAR 的总费用仍明显高于标准 EVAR。这可能是由于开窗式血管内移植物的额外成本以及与 FEVAR 相关的并发症发生率增加所致。
