Hybrid Aortic Repair: Effective but Costly

BY BRUCE JANCIN

Combined aortic debranching and thoracoabdominal aortic endovascular repair is a less invasive alternative to open surgical repair of complex aortic aneurysms that provides better outcomes even in older, sicker patients.

The bad news is that direct hospital costs are higher, and reimbursement is lower than for conventional open surgery. This results in a 34% net financial loss on each patient with a hybrid procedure, Dr. Erin H. Murphy said at the annual meeting of the Western Surgical Association.

In contrast, open surgical repair provides the hospital with a net 6% profit, added Dr. Murphy of the University of Texas Southwestern Medical Center, Dallas.

Multiple small series, the largest involving 15-30 patients, have demonstrated that the hybrid procedure entails some attractively low rates of operative mortality, spinal cord ischemia, and perioperative morbidity. In contrast, open repair is associated with 10%-20% operative mortality rates, renal failure in 15%-30% of cases, pulmonary complications in 20%-40%, and spinal cord ischemia in up to 15%. However, there had been no prior hospital cost analyses.

To remedy this, Dr. Murphy reviewed the records of 27 Southwestern patients with aortic pathology involving branch vessels. Of those, 15 underwent hybrid repair because they were at high risk for open repair and had anatomy unsuited for endografting alone. The other 12 underwent conventional open repair. Both groups were similar in location of aortic pathology.

The hybrid repair was performed in a single session. The procedure is used as an alternative to two-stage open surgery in patients with complex aneurysms of the proximal descending thoracic aorta and/or distal aortic arch with branch vessel involvement. Aortic debranching and placement of an elephant graft are performed surgically through a sternotomy. Aneurysm exclusion is then completed by means of thoracoabdominal endovascular repair via peripheral access of instruments and devices. Endovascular completion spares high-risk patients a left lateral thoracotomy, aortic cross-clamping, and extensive exposure.

The patients who had hybrid repair averaged 73 years of age, versus 58 for the open-repair group. Six patients in the hybrid-repair group had significant coronary artery disease; one in the open-repair group. Nonetheless, the hybrid-repair group had significantly less intraoperative blood loss, fewer transfusions, lower rates of major in-hospital complications, fewer days on the mechanical ventilator, and less time in the ICU (see chart).

Cost data supplied by the hospital showed the average total direct and indirect in-hospital cost of a hybrid repair was just under $82,000, compared with $76,000 for open repair. But reimbursement by both Medicare and private insurers was markedly less for hybrid repair, with a resultant negative 34% mean cost margin.

"The Gore TAG endoprostheses cost about $10,000 apiece. ... We're all hoping the cost of grafts will come down," Dr. Murphy continued.

Dr. Laurens R. Pickard of Baylor College of Medicine, Houston, observed that total costs associated with hybrid repair would have been far greater had Dr. Murphy included the expense of post-hospital follow-up CT surveillance of the endografts along with treatment of endoleaks.

Dr. Murphy replied that those costs are very much in flux, with a sharp downward trend. Routine CT is giving way to less costly ultrasound, and it is apparent that not all endoleaks require treatment.