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Ann Thorac Surg 2009;87:1801-1805. doi:10.1016/j.athoracsur.2009.02.099
© 2009 The Society of Thoracic Surgeons
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Original Articles: Adult Cardiac

Endovascular and Conventional Treatment of Thoracic Aortic Aneurysms: A Comparison of Costs

Ingrid Schuster, MDa,*, Marion Dorfmeister, MDb,*, Sandra Scheuter-Mlaker, MDc, Roman Gottardi, MDb, Michael Hoebartner, MSb, Suzanne Roedler, MDb, Tomasz Dziodzio, MSb, Andrzej Juraszek, MSb, Christian Loewe, MDd, Martin Funovics, MDd, Johannes Holfeld, MSb, Julia Dumfarth, MDb, Daniel Zimpfer, MDb, Maria Schoder, MDd, Johannes Lammer, MDd, Michael Grimm, MDb, Martin Czerny, MDb,*

a Eastern Slovakian Institute of Cardiovascular Diseases, Kosice, Slovakia
b Department of Cardiothoracic Surgery, Medical University of Vienna, Vienna, Austria
c Department of Controlling and Finance, Medical University of Vienna, Vienna, Austria
d Department of Interventional Radiology, Medical University of Vienna, Vienna, Austria

Accepted for publication February 20, 2009.

* Address reprint requests to Dr Czerny, Waehringer Guertel 18-20, Vienna, A-1090, Austria (Email: martin.czerny{at}meduniwien.ac.at).


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 Footnotes
 References
 
Background: The purpose of this study is to compare costs of conventional surgical therapy with costs of endovascular stent-graft placement in patients with thoracic aortic aneurysms.

Methods: Fifteen patients undergoing either conventional surgical therapy or endovascular stent-graft placement of thoracic aortic aneurysms were analyzed. A catalog of costs was then created for both procedures and this catalog was applied individually to each patient.

Results: Total costs of the service provision of endovascular stent-graft placement including anesthesia were 38.220.98{euro} considering 1.7 stent-grafts per patient and including 5900.00{euro} (Euros) for days of care. In conventional surgical therapy, adding the costs of the service provision of left heart catheterization, conventional surgical therapy including anesthesia, as well as intraoperative echocardiography a sum of 19.534.12{euro} was calculated. Days of care accounted for 31.230.00{euro} and total costs of 50.764.12{euro} were calculated. The difference between total costs of the two procedures was 12.543.14{euro}.

Conclusions: Costs of endovascular stent-graft placement in patients with thoracic aortic aneurysms compare favorably with conventional surgical therapy, revealing a cost benefit of 24.7%. Higher procedural costs are outweighed by a lower number of days of care. Nevertheless, aneurysm-related secondary endovascular or surgical procedures may balance the benefit of endovascular therapy. Which strategy to choose, conventional or endovascular, should remain to be based on age, comorbidity, and technical feasibility.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 Footnotes
 References
 
The aim of treatment in patients with thoracic aortic aneurysms is to prevent rupture. Recently, endovascular stent-graft placement has proven to be equally effective but less invasive by reducing intraprocedural and postprocedural morbidity and mortality in these patients [1–4]. Nevertheless, costs of the graft itself vary tenfold between a conventional and an endovascular prosthesis. Economic aspects are becoming of increased importance in general health care. As a consequence, newly introduced treatment modalities are not only evaluated by their efficacy but also by their cost effectiveness.

The aim of this study was to compare costs of conventional surgical therapy with costs of endovascular stent-graft placement in patients with thoracic aortic aneurysms.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 Footnotes
 References
 
Fifteen patients undergoing either conventional surgical therapy or endovascular stent-graft placement of thoracic aortic aneurysms were analyzed. Patients were selected to the following criteria: suitability for both procedures, regular anatomy (ie, no involvement of supraaortic or visceral branches) and absence of extensive cardiac, supraaortic as well as peripheral disease.

Cost Analysis
To evaluate the net costs of both procedures, a cost calculation was performed by our hospital's controlling and finance department. A catalogue of costs was then created for both procedures and this catalogue was applied individually to each patient.

Labor Costs
These costs include surgeons, radiologists, anesthesiologists, and nurses, as well as radiology technicians. The number of members of the professional categories involved as well as their average time input in minutes for the individual procedure was calculated.

Medical Supplies
These costs include the type of prosthesis used, conventional Dacron graft (Vascutek Ltd, Inchinnan, Scotland) or endovascular stent-graft, as well as each single item needed for the individual procedure. As (dependent onto the length of the lesion) more than one stent-graft has to be used, an average number of 1.7 stent-grafts was implanted. As anesthesiologic medical supplies in conventional surgery are by far more extensive (red packed blood cells, fresh frozen plasma, thrombocytes, as well as coagulation factors) these supplies are listed separately.

Installation Costs
These costs include use of installed equipment. Listed matters include purchase costs, expected useful life in years, blocking time per year, blocking time per procedure, installation costs per year as well as total costs of the procedure itself.

Occupancy Costs and Surcharges
Occupancy costs for surgical interventions are calculated in terms of so-called operation-overhead rates. Independent of the individual surgical service provision, a fixed percentage of 52.58% is being added.

In nonoperative service provisions (like preoperative diagnostic coronary angiography or intraoperative transesophageal echocardiography) a different charging system is applied. This system contains an administration overhead rate of 24.76%, a providing or storage overhead rate of 13.34%, and a pretax loading for expenses of 11.10%. Occupancy costs are calculated in minutes per square meter with a rate of 0.005{euro} (Euro) per minute.

Days of Care, Follow-Up, and Currency
Days of care and their costs according to the days spent on the intensive care unit as well as on the regular ward were evaluated. As all patients receive routine completion computed tomographic (CT) scans before discharge and then annually thereafter, this factor was not included in this analysis as we would not expect any difference. All expenses are given in Euros.

Stent-Graft Placement
Stent grafts were placed under general anesthesia. In all patients, a common femoral artery access was chosen. A 5-French pigtail catheter was advanced via the right brachial artery into the aortic arch to reconfirm characterization of the morphology and extent of the lesion. The stent-graft was deployed during systemic hypotension with a systolic pressure of 60 mm Hg. The mean number of stent-grafts used was 1.7.

Conventional Surgical Therapy
After a standard posterolateral approach, extracorporeal circulation was initiated. After cross-clamping, the proximal anastomosis was performed. Consequently, if appropriate, intercostal vessels were reattached in an island fashion. Afterward the distal anastomosis was performed and extracorporeal circulation was discontinued. One Dacron prosthesis (Vascutek Ltd) was used per patient.


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 Footnotes
 References
 
Endovascular Stent-graft Placement
Endovascular stent-graft placement including anesthesia
The total labor costs of endovascular stent-graft placement including anesthesia are 1.757.60{euro}. A detailed list of labor costs is depicted in Table 1. Total costs of medical supplies are 11.131.40{euro}. Details are depicted in Appendix 1.** Installation costs are 1.074.27{euro}. Details are depicted in Table 2. Summarizing, the net sum of labor costs, costs of medical supplies as well as installation costs is 13.963.36{euro}. The operation-overhead rate of 52.58 % is 7.341.89{euro}. As a consequence, total costs of the service provision of endovascular stent-graft placement including anesthesia are 21.305.16{euro}.


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  		Table 1 Endovascular Stent-Graft Placement Including Anesthesia and Labor Costs
 

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  		Appendix 1 Endovascular Stent-Graft Placement Including Anesthesia: Medical Supplies
 

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  		Table 2 Endovascular Stent-Graft Placement Including Anesthesia: Installation Costs
 
Endovascular stent-graft placement including anesthesia-additional stent-graft requirement
It was mentioned previously, that a mean of 1.7 stent grafts were used per patient. As a consequence, another service provision had to be created being termed "endovascular stent-graft placement including anesthesia-additional stent-graft requirement." The total labor costs of this service provision are 123.20{euro}. The entire costs of medical supplies are 10.118.85{euro}. Installation costs are 71.82{euro}. Summarizing, the net sum of labor costs, costs of medical supplies as well as installation costs is 10.313.86{euro}.The operation-overhead rate of 52.58 % is 5423.03{euro}. As a consequence, total costs of the service provision of endovascular stent-graft placement including anesthesia-additional stent-graft requirement are 15.736.89{euro}.

Conventional Surgical Therapy
Left heart catheterization
In contrast to stent-graft placement, each patient is subjected to left heart catheterization routinely. Labor costs of the service provision "left heart catheterization" are 193.20{euro}. Costs of medical supplies are 681.22{euro}. Installation costs are 307.53{euro}. As left heart catheterization is no surgical service provision, occupancy costs of 17.32{euro} are levied. Overhead rate of administration, providing or storage and pretax account for 150.35{euro}. Summarizing, total costs of the service provision "left heart catheterization" are 1486.50{euro}.

Conventional surgical therapy including anesthesia
Total labor costs of the service provision "conventional open repair" are 3.172.20{euro}. A detailed list of labor costs is shown in Table 3. Costs of surgical and perfusion medical supplies are 3.340.51{euro} and are listed separately (Appendix 2 **). Anesthesiologic medical supplies account for 4.727.48{euro} and are also listed separately (Appendix 3 **). Installation costs are 272.76{euro}. Details are shown in Appendix 4.** Summarizing, total costs of labor, medical supplies and equipment are 11.512.95{euro}. The operation-overhead rate of 52.58 % accounts for 6.053.51{euro}. As a consequence, total costs of the service provision "Conventional surgical therapy including anesthesia" are 17.566.46{euro}.


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  		Table 3 Conventional Surgical Therapy Including Anesthesia-Labor Costs
 

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  		Appendix 2 Conventional Surgical Therapy Including Anesthesia: Medical Supplies of Surgery and Perfusion
 

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  		Appendix 3 Conventional Surgical Therapy Including Anesthesia: Medical Supplies of Anesthesiology
 

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  		Appendix 4 Conventional Surgical Therapy Including Anesthesia: Installation Costs
 
Intraoperative echocardiography
Intraoperative echocardiography is applied routinely in patients undergoing conventional surgical therapy. Labor costs of the service provision "intraoperative echocardiography" are 127.80{euro}. Costs of medical supplies are 379.77{euro}. Installation costs are 20.24{euro}. As intraoperative echocardiography is no surgical performance, occupancy costs of 3.00{euro} are levied. Overhead rates of administration, providing or storage, and pretax account for 150.35{euro}. Summarizing, total costs of the service position "intraoperative echocardiography" are 681.16{euro}.

Adding the costs of the service provision of left heart catheterization, conventional surgical therapy including anesthesia, as well as intraoperative echocardiography, a sum of 19.534.12{euro} is calculated.

Days of Care
Endovascular stent-graft placement
The day rate on the regular ward in our hospital is 1.180.00{euro}. The mean length of stay in this patient cohort was 5 days thereby accounting for 5.900.00{euro} per patient.

Conventional surgical therapy
The day rate on the intensive care unit in our hospital is 3.014.00{euro}. The mean length of stay in patients after conventional surgical therapy on the intensive care unit was 5 days, thereby accounting for 15.070.00{euro} per patient. The mean length of stay on the regular ward was 12 days, thereby accounting for an additional 14.160{euro}. As a consequence, costs for days of care account for 31.230.00{euro} per patient.

Total Costs of the Service Provision "Endovascular Stent-graft Placement"
Total costs of the service provision "Endovascular stent-graft placement including anesthesia" are 21.305.16{euro}. A mean of 1.7 prostheses have been used per patient. Therefore, additional costs of 11.015.82{euro} per intervention arise being termed "Endovascular stent-graft placement including anesthesia-additional stent-graft requirement". Days of care account for 5900.00{euro}. Summarizing, total costs of 38.220.98{euro} are calculated.

Total Costs of the Service Provision "Conventional Surgical Therapy"
Adding the costs of the service provision of left heart catheterization, conventional surgical therapy including anesthesia, as well as intraoperative echocardiography a sum of 19.534.12{euro} is calculated. Days of care account for 31.230.00{euro}. Summarizing, total costs of 50.764.12{euro} are calculated.

Difference of Costs Between Treatment Strategies
The difference between total costs of the two procedures is 12.543.14{euro}. As a consequence, the cost benefit of endovascular stent-graft placement is 24.7% as compared with conventional surgical therapy.


   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
Footnotes
 References
 
Midterm results of endovascular stent-graft placement are well-established and the less invasiveness in face of primary equal effectiveness is evident. Despite this fact, costs have remained a matter of discussion especially due to the high costs of the stent-graft prosthesis itself. As a consequence, others [5, 6] have already compared costs in patients undergoing abdominal aortic repair revealing that stent-graft placement in these patients does at least not incur substantial additional costs. Limited data regarding costs between stent-graft placement and conventional surgical repair in patients with thoracic aortic aneurysms are available [7].

Regarding labor costs, a summative saving in favor of stent-graft placement could be observed. As the rate per minute of all specialties involved is equal, this saving is directly related to the shorter duration of the procedure. When focusing on medical supplies, costs of stent-graft placement are substantially higher, resulting from the logical consequence of the price per unit as well as from the fact that a median of 1.7 stent-graft prostheses per patient was used. When going into detail of conventional surgery the biggest assets are blood products, as plasmatic and cellular coagulation have to be extensively substituted after extracorporeal circulation. Installation costs of stent-graft placement are higher. Apparative complexity is substantial in both procedures; however, acquisition costs of technical apparatus for stent-graft placement are more extensive resulting in higher total costs per procedure according to blocking time per service provision. Occupancy costs and surcharges are equal and show limited influence on the net sum. Diagnostics are more extensive in patients undergoing conventional aortic aneurysm repair. Left heart catheterization is being performed routinely accounting for additional expenses. Furthermore, intraoperative echocardiography accounts for additional costs. Both service specialties are not routinely required in patients undergoing stent-graft placement.

Most importantly, days of care differ substantially between both methods. Patients after stent-graft placement do not require an intensive care unit stay in our setting and the cumulative in-hospital stay is limited to 5 days. In patients after conventional aortic aneurysm repair, the median stay on the intensive care unit is 5 days. Furthermore, the mean stay on the regular ward is 12 days thereby accounting for a substantial increase of costs. As a consequence, comparison of costs of both procedures revealed a cost benefit of 24.7% of stent-graft placement as compared with conventional surgical therapy.

Nevertheless it has to be critically discussed that patients after endovascular stent-graft placement may need subsequent procedures or even late surgical conversion due to therapy failure, most importantly, endoleak formation [8]. Obviously, a single redo procedure may balance the ostensible cost effectiveness of stent-graft placement. Therefore, our findings have to be interpreted with caution and may not be seen as a general license for endovascular therapy. Additionally, this analysis is not aimed to influence clinical decision making which strategy, conventional or endovascular, to choose based on financial reasons as this has to be done solely by age, comorbidity, and technical feasibility. In our setting a critical risk stratification is being performed. As a consequence, younger and fitter patients do undergo conventional surgery. In patients undergoing endovascular stent-graft placement, merely 15% are deemed suitable for conventional surgery due to their clinical performance, their comorbidities, and their functional reserve [9].

Furthermore, surveillance costs are an issue as patients after stent-graft placement may require a higher number of follow-up CT scans than patients after conventional surgery especially when clinically silent endoleaks are detectable and being serially reevaluated. The potentially higher late death rate in other observations remains speculative and due to our current knowledge it remains open if these higher death rate is directly aortic related or not [10, 11]. Future investigations will help to determine if this observation could be due to the higher initial risk and associated comorbidity in these patients or due to yet unknown factors such as material fatigue and late endoleak formation.

This study has been conducted within a single center according to the individual costs in this setting. Without doubt the distribution of costs in individual service provisions will be different in other settings. Nevertheless, we are confident to be able to provide an objective description of the economic aspects of this issue where the quintessence can also be transferred to other centers.

Summarizing, costs of endovascular stent-graft placement in patients with thoracic aortic aneurysms compare favorably with conventional surgical therapy, revealing a cost benefit of 24.7%. Higher procedural costs are outweighed by a lower number of days of care. Nevertheless, aneurysm-related secondary endovascular or surgical procedures may balance the benefit of endovascular therapy. Which strategy to choose, conventional or endovascular, should remain to be based on age, comorbidity, and technical feasibility.


   Appendix
 


   Footnotes
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Footnotes
References
 
The Appendices are available online only. To access them, please visit: http://ats.ctsnetjournals.org and search for the article by Schuster et al, Vol. 87, pages 1801–1805.

* The first two authors have equally contributed to this work. Back

** See note at end of article regarding e-only Appendices. Back

** See note at end of article regarding e-only Appendices. Back


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Footnotes
 References
 

  1. Svensson LG, Kouchoukos NT, Miller DC, et al. Expert consensus document on the treatment of descending thoracic aortic disease using endovascular stent-grafts Ann Thorac Surg 2008;85(1 Suppl):S1-S41.[Abstract/Free Full Text]
  2. Rousseau H, Bolduc JP, Dambrin C, Marcheix B, Canevet G, Otal P. Stent-graft repair of thoracic aortic aneurysms Tech Vasc Interv Radiol 2005;8:61-72.[Medline]
  3. Bavaria JE, Appoo JJ, Makaroun MS, Verter J, Yu ZF, Mitchell RS. Endovascular stent grafting versus open surgical repair of descending thoracic aortic aneurysms in low-risk patients: a multicenter comparative trial J Thorac Cardiovasc Surg 2007;133:369-377.[Abstract/Free Full Text]
  4. Czerny M, Grimm M, Zimpfer D, et al. Results after endovascular stent-graft placement in atherosclerotic aneurysms involving the descending aorta Ann Thorac Surg 2007;83:450-455.[Abstract/Free Full Text]
  5. Hölzenbein J, Kretschmer G, Glanzl R, et al. Endovascular AAA treatment: expensive prestige or economic alternative? Eur J Vasc Endovasc Surg 1997;14:265-272.[Medline]
  6. Sternbergh WC, Money SR. Hospital costs of endovascular versus open repair of abdominal aortic aneurysms: a multicenter study J Vasc Surg 2000;31:237-244.[Medline]
  7. Glade GJ, Vahl AC, Wisselink W, Linsen MA, Balm R. Mid-term survival and costs of treatment of patients with descending thoracic aortic aneurysms; endovascular vs. open repair: a case-control study Eur J Vasc Endovasc Surg 2005;29:28-34.[Medline]
  8. Grabenwoger M, Fleck T, Ehrlich M, et al. Secondary surgical interventions after endovascular stent-grafting of the thoracic aorta Eur J Cardiothoracic Surg 2004;26:608-613.[Abstract/Free Full Text]
  9. Gottardi R, Funovics M, Eggers N, et al. Supra-aortic transposition for combined vascular and endovascular repair of aortic arch pathology Ann Thorac Surg 2008;86:1524-1529.[Abstract/Free Full Text]
  10. Buth J, Harris PL, Hobo R, et al. Neurologic complications associated with endovascular repair of thoracic aortic pathology: Incidence and risk factors. A study from the European Collaborators on Stent/Graft Techniques for Aortic Aneurysm Repair (EUROSTAR) registry. J Vasc Surg 2007;46:1103-1111.[Medline]
  11. Leurs LJ, Harris PL, Buth J, EUROSTAR Collaborators Secondary interventions after elective endovascular repair of degenerative thoracic aortic aneurysms: results of the European collaborators registry (EUROSTAR) J Vasc Interv Radiol 2007;18:491-495.[Medline]



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