From the Society for Clinical Vascular Surgery

Cost analysis of endovascular versus open repair in

the treatment of thoracic aortic aneurysms
Jacob R. Gillen, MD, Basil W. Schaheen, MD, Kenan W. Yount, MD, MBA, Kenneth J. Cherry, MD,
John A. Kern, MD, Irving L. Kron, MD, Gilbert R. Upchurch Jr, MD, and Christine L. Lau, MD, MBA,
Charlottesville, Va

Objective: For descending thoracic aortic aneurysms (TAAs), it is generally considered that thoracic endovascular aortic repairs
(TEVARs) reduce operative morbidity and mortality compared with open surgical repair. However, long-term differences in
survival of patients have not been demonstrated, and an increased need for aortic reintervention has been observed. Many
assume that TEVAR becomes less cost-effective through time because of higher rates of reintervention and surveillance im-
aging. This study investigated midterm outcomes and hospital costs of TEVAR compared with open TAA repair.
Methods: This was a retrospective, single-institution review of elective TAA repairs between 2005 and 2012. Patient de-
mographics, operative outcomes, reintervention rates, and hospital costs were assessed. The literature was also reviewed to
determine commonly observed complication and reintervention rates for TEVAR and open repair. Monte Carlo simulation
was used to model and to forecast hospital costs for TEVAR and open TAA repair up to 3 years after intervention.
Results: Our cohort consisted of 131 TEVARs and 27 open repairs. TEVAR patients were significantly older (67.2 vs 58.7 years
old; P [ .02) and trended toward a more severe comorbidity profile. Operative mortality for TEVAR and open repair was 5.3%
and 3.7%, respectively (P [ 1.0). There was a trend toward more complications in the TEVAR group, although not statistically
significant (all P > .05). In-hospital costs were significantly greater in the TEVAR group ($52,008 vs $37,172; P [ .001).
However, cost modeling by use of reported complication and reintervention rates from the literature overlaid with our cost data
produced a higher cost for the open group in-hospital ($55,109 vs $48,006) and at 3 years ($58,426 vs $52,825). Interestingly,
TEVAR hospital costs, not reintervention rates, were the most significant driver of cost in the TEVAR group.
Conclusions: Our institutional data showed a trend toward lower mortality and complication rates with open TAA repair,
with significantly lower costs within this cohort compared with TEVAR. These findings were likely, at least in part, to be
due to the milder comorbidity profile of these patients. In contrast, cost modeling by Monte Carlo simulation demon-
strated lower costs with TEVAR compared with open repair at all time points up to 3 years after intervention. Our
institutional data show that with appropriate selection of patients, open repair can be performed safely with low
complication rates comparable to those of TEVAR. The cost model argues that despite the costs associated with more
frequent surveillance imaging and reinterventions, TEVAR remains the more cost-effective option even years after TAA
repair. (J Vasc Surg 2015;61:596-603.)

With the advent of less invasive approaches, the man-
agement and treatment of thoracic aortic aneurysms
(TAAs) have undergone significant changes in recent
years. There has been a movement away from the tradi-
tional open repair in favor of less invasive endovascular
techniques, collectively known as thoracic endovascular
aortic repairs (TEVARs).1,2 Early data have demonstrated
lower in-hospital complication and mortality rates in
From the Division of Thoracic and Cardiovascular Surgery, Department of
Surgery, University of Virginia Health System.
Author conflict of interest: none.
Presented at the Forty-second Annual Symposium of the Society for Clinical
Vascular Surgery, Carlsbad, Calif, March 18-22, 2014.
Reprint requests: Christine L. Lau, MD, MBA, Department of Surgery,
University of Virginia Health System, PO Box 800679, Charlottesville,
VA 22908-0679 (e-mail: cll2y@hscmail.mcc.virginia.edu).
The editors and reviewers of this article have no relevant financial relationships
to disclose per the JVS policy that requires reviewers to decline review of any
manuscript for which they may have a conflict of interest.
0741-5214
Copyright Ó 2015 by the Society for Vascular Surgery. Published by
Elsevier Inc.
http://dx.doi.org/10.1016/j.jvs.2014.09.009
TEVAR compared with open repair.1,3-8 Therefore,
TEVAR has become the first-line choice for TAA treat-
ment by many vascular surgeons.
Despite these advantages in the short term, the long-
term superiority of TEVAR has not been demonstrated.
In most studies, the 1-year survival for TEVAR is not
significantly higher than that for open repair.1,3,4,8-11 In
addition, TEVARs have higher reintervention rates, pre-
dominantly due to the development of endoleaks, a
complication rarely seen in open repairs.6,9,10,12,13
The current medical and financial climate in health care
necessitates attention to the cost-effectiveness of our treat-
ment practices in addition to standard postoperative out-
comes. Several studies have demonstrated that TEVARs
typically have in-hospital costs that are similar to or lower
than those of open repair.3,6,7,10,11,14 However, many indi-
viduals presume that TEVARs generate higher costs
through time because of more frequent reinterventions
and more frequent surveillance chest computed tomogra-
phy scans.6,14 To date, there have been only small single-
center studies to evaluate the relative costs of the respective
TAA repair strategies over time.

596
JOURNAL OF VASCULAR SURGERY
Volume 61, Number 3
Therefore, the purpose of this study was to investigate
the cost-effectiveness of TEVAR vs open repair for elective
TAA repair by use of a Monte Carlo simulation to model
and to forecast hospital costs up to 3 years after interven-
tion. We hypothesized that TEVAR will become more
expensive through time because of higher rates of reinter-
vention and increased surveillance imaging compared
with open repair.
METHODS
Patient selection and data acquisition. The Institu-
tional Review Board at the University of Virginia
(#16496) approved this study. Because of its retrospective
design with de-identification of patient data, consent was
waived. A retrospective review was performed of all elec-
tive repairs of isolated TAAs at our institution between
March 2005 and July 2012. TAA repair patients were
stratified into two primary cohorts: open repair and
endovascular repair (TEVAR). Exclusion criteria included
emergent procedures (<24 hours from an unplanned
admission), concomitant repair of the abdominal aorta
(thoracoabdominal aneurysms), acute traumatic injury,
repair for dissection without aneurysmal component
(defined as aortic diameter > 4.5 cm), repair for pene-
trating ulcers, planned elephant trunk procedures, and
laparotomy for direct aortic cannulation for stent delivery
and deployment. Aneurysms with concomitant aortic
dissections were included, as were repairs for aortic
pseudoaneurysms. Of note, TEVARs that required sub-
sequent open repair during the same hospitalization were
categorized within the endovascular repair group (intent-
to-treat analysis).
Patients between the cohorts were compared by demo-
graphics, preoperative comorbidities, operative outcomes,
complication rates, and occurrences of readmission and
reintervention.
Cost data acquisition. Hospital cost data were ob-
tained for each patient’s index hospitalization as well as
for subsequent readmissions that were related to compli-
cations of the aortic intervention from hospital inpatient
discharge financial data. Of note, this was the cost of
care as estimated by the institution, not the charges
relayed to patients and insurers and not hospital reim-
bursement figures. The average cost of an index hospital-
ization without complications both for TEVAR and for
open repair was determined, as was the average marginal
increase in hospital costs with various complications (eg,
paralysis, stroke, myocardial infarction, major bleeding
event, respiratory complication). Major bleeding event
was defined as hemorrhage requiring operative reinterven-
tion or bleeding within the mediastinum. Respiratory
complications were defined as a mechanical ventilation
requirement longer than 48 hours, reintubation, or
discharge with a new home oxygen requirement. The
average hospital costs of readmission with an open aortic
intervention, readmission with an endovascular interven-
tion, and readmission with no intervention were also
determined.
Gillen et al 597
Outcomes and cost modeling. The primary outcome
of interest was the forecasted differences in hospital costs
up to 3 years after intervention as determined by Monte
Carlo simulation (described later). The forecasted model
was used to create a more precise estimate of hospital costs
that could be applied to other institutions, depending on
their local experience and complication rates with TEVAR
and open TAA repair, as well as to highlight the primary
cost drivers in each cohort.
Monte Carlo simulation was used to model and to
forecast hospital costs for TEVAR and open TAA repair
in the hospital as well as at 1 year and 3 years after interven-
tion. Complication and reintervention rates were deter-
mined by the weighted averages and ranges of rates
observed in the literature as this was more likely to be
representative of the complication and reintervention
rates at other institutions, rather than with use of the
observed rates within our single-institution cohort1,3-22
(Supplementary Table). Triangular probability distribu-
tions (using a minimum, most likely, and maximum value)
and log normal distributions, rather than a normal proba-
bility distribution, were used for the majority of complica-
tion and reintervention rates, given the relatively small
sample of rates reported in the literature. Cost values for in-
dex hospitalizations as well as marginal cost increases asso-
ciated with various complications and reinterventions were
determined with our institutional cost data as described
before. Patients were categorized on the basis of their
initial procedure (TEVAR vs open) but were able to un-
dergo subsequent interventions from either procedure
type within the model. The model was designed as a
sequential cascade with multiple decision points in which
potential rates of complications, rates of reinterventions,
and unvaried costs such as surveillance imaging were
used. The primary decision points were (1) during the in-
hospital window, with variability in rates of complications
between the TEVARs and open repairs; (2) at 1 year after
intervention, with variability in rates of readmission and
reintervention between the two groups; and (3) at 3 years
after intervention, with similar variability in the cumulative
rates of reinterventions. The values and sequential time
points ultimately used to construct our model are pre-
sented in Table I.
Marginal costs with each complication and reinterven-
tion were determined on the basis of our institutional cost
data and discounted to year 0 dollars by a discount rate of
10%. Given the low complication rates within our institu-
tion’s open cohort, cost data for each complication from
both TEVARs and open repairs were pooled to determine
the most likely marginal cost for each complication. Simi-
larly, reintervention cost data from both TEVARs and
open repairs were pooled for the simulation.
Provided there were no complications, cost of surveil-
lance imaging in the TEVAR cohort was added to our
model at 1 month, 6 months, 12 months, and then every
12 months after intervention. In open repairs, surveillance
imaging was performed at 12 months after intervention,
provided there were no complications. The forecasted costs
 JOURNAL OF VASCULAR SURGERY
598 Gillen et al March 2015

Table I. Cost model variables

TEVAR Open

% Cost ($) % Cost ($)

In-hospital
No complications 82.5 42,110 60 38,612
Paralysis 2 þ110,498 4 þ110,498
Stroke 3 þ11,780 5 þ11,780
Myocardial infarction 2 þ43,956 5 þ43,956
Major bleeding event 0.5 þ178,143 3 þ178,143
Respiratory complication 10 þ17,200 23 þ17,200
1 year after intervention
Surveillance CT scans ($180) 3 540 1 180
No readmission 82.2 From in-hospital 90 From in-hospital
Angiographic reintervention 6.8 þ24,643 1.5 þ24,643
Open reintervention 4 þ41,114 1.5 þ41,114
Readmission þ no intervention 7 þ8075a 7 þ24,460a
3 years after intervention
Surveillance CT scans ($180) 5 900 1 180
No readmission 79.2 From in-hospital 88.5 From in-hospital
Angiographic reintervention 8.8 þ24,643 2.25 þ24,643
Open reintervention 5 þ41,114 2.25 þ41,114
Readmission þ no intervention 7 þ8075a 7 þ24,460a

CT, Computed tomography; TEVAR, thoracic endovascular aortic repair.

a
Open patients who were readmitted without an intervention demonstrated more significant and more costly reasons for admission (eg, wound infection,
epidural abscess) compared with TEVAR patients, and therefore a higher cost for readmission was used in the model.

from our simulations are reported with a mean, median, Table II. Preoperative patient characteristics
and 25th and 75th percentiles based on 100,000 iterations.
To determine the primary drivers of cost in both the Variable TEVAR (n ¼ 131) Open (n ¼ 27) P value
TEVAR and open repair cohorts, a sensitivity analysis was
Age, years 67.22 58.74 .02
performed. Each component used by our cost model was
a potential driver of cost within the sensitivity analysis, % No. % No. P value
including the rate of no intervention in TEVAR, cost of
no intervention in TEVAR, rate of paralysis in TEVAR, Male gender 56.5 74 51.9 14 .68
rate of angiographic intervention in TEVAR, cost of angio- Hypertension 84.7 111 88.9 24 .77
graphic intervention in TEVAR at 1 year, and so on. Each Coronary artery disease 47.3 62 25.9 7 .05
Stroke 17.6 23 11.1 3 .26
potential driver of cost was then individually varied within a Diabetes 7.6 10 0.0 0 .21
range of
10% to þ10% of the mean value assumed by the Chronic renal insufficiency 20.6 27 18.5 5 1.00
model. Forecasts were produced at each end of this range, Dialysis dependent 2.3 3 3.7 1 .53
and drivers were ranked according to estimated change Chronic obstructive 26.7 35 18.5 5 .47
pulmonary disease
produced in the forecast. Therefore, the drivers that gener-
ated the largest effect on cost output when varied within TEVAR, Thoracic endovascular aortic repair.
the model were deemed the strongest drivers of hospital
cost.
Statistical analysis. Dichotomous variables were eval- higher incidence of comorbidities in the TEVAR group,
uated by the c2 or Fisher exact test as appropriate, and particularly with coronary artery disease (Table II). How-
continuous variables were compared by the Student ever, patient age was the only measure that was significantly
t-test. All data analysis was performed in Microsoft Excel different between the two cohorts, with TEVAR patients
(Redmond, Wash), and the Monte Carlo simulation was being significantly older (67.2 vs 58.7 years old; P ¼ .02).
performed with Oracle Crystal Ball (Redwood Shores, Postoperative outcomes were similar between the two
Calif). groups. There was no significant difference in hospital
length of stay, intensive care unit length of stay, discharge
RESULTS to home, 30-day mortality, or 1-year mortality (Table III).
Comparison of patient risk factors and outcomes. However, in evaluating the subgroup of patients with no
Between March 2005 and July 2012, 131 TEVARs and 27 complications, the hospital length of stay in TEVARs was
open TAA repairs were performed at our institution. Of significantly shorter than in open repairs (5.5 vs 7.3 days;
note, three of the TEVAR patients required open repair P ¼ .03). There was a trend toward more complications
during the same hospitalization. There was a trend toward and more reinterventions in the TEVAR group, although
JOURNAL OF VASCULAR SURGERY
Volume 61, Number 3 Gillen et al 599

these differences were not statistically significant. Average Table III. Postoperative outcomes, complications, and
length of follow-up documented within the medical record costs
was similar among TEVARs and open repairs (24.6 vs
28.1 months; P ¼ .55). TEVAR Open
(n ¼ 131) (n ¼ 27)
Comparison of institutional hospitalization costs.
P
In analyzing hospital costs during the admission of the in- Variable Mean SD Mean SD value
dex procedure, TEVAR patients had significantly higher
costs compared with patients undergoing open TAA re- LOS, days 7.6 9.3 7.3 3.3 .76
pairs ($52,008 vs $37,172; P ¼ .001; Table III). How- ICU LOS, hours 120.5 198.0 98.7 58.7 .30
ever, among the subgroup of patients with no LOS (no complications), 5.5 3.8 7.3 3.4 .03
days
complications, there was no significant difference between ICU LOS (no complications), 76.8 61.2 97.5 60.6 .14
TEVAR and open repair ($42,110 vs $38,612; P ¼ .22). hours
Of note, the average reimbursement for uncomplicated
TAA repair was $43,468 for TEVAR (diagnosis related % No. % No. P value
group 39.73) and $40,871 for open repair (diagnosis
related groups 38.44 and 38.45). Paralysis and major Stroke 5.30 7 0.00 0 .60
Paralysis 2.30 3 0.00 0 1.00
bleeding event were the complications that most dramati- Major bleeding event 2.30 3 0.00 0 1.00
cally increased the cost of the index hospitalization, Myocardial infarction 3.10 4 3.70 1 1.00
generating increases of $110,498 and $178,143, respec- Respiratory complication 14.50 19 11.10 3 1.00
tively. At 3 years after intervention, TEVAR costs remained Any complication 23.70 31 14.80 4 .45
Discharged to home 79.40 104 77.80 21 .80
significantly higher than open repair costs ($59,709 vs
30-day mortality 5.30 7 3.70 1 1.00
$43,787; P ¼ .005; Table III). 1-year mortality 13.00 17 14.80 4 .76
Comparison of forecasted hospitalization costs. Reinterventions at 1 year 13.70 18 3.70 1 .20
The results of our literature review on complication and Reintervention at 3 years 17.60 23 11.10 3 .57
reintervention rates for both TEVAR and open TAA repair
are shown in Table IV. Of note, there are some distinct Mean SD Mean SD P value
differences compared with our institutional rates. For one,
In-hospital cost $52,008 $40,256 $37,172 $14,483 .001
the complication rates for our institution’s open repair Hospital cost at $59,709 $45,984 $43,787 $20,062 .005
cohort are very low compared with the rates reported in the 3 years
literature. In addition, the literature consistently demon-
ICU, Intensive care unit; LOS, length of stay; SD, standard deviation;
strates a more favorable complication profile in TEVARs TEVAR, thoracic endovascular aortic repair.
compared with open repairs, whereas our institution’s data
demonstrate the opposite, with higher complication rates
within our TEVAR cohort.
these cumulative costs reflect the sum of predicted costs
Table I displays the values used to construct our cost
for the index operation, hospitalization, postoperative sur-
model. Again, the rates were determined from the liter-
veillance, complications, reinterventions, and readmissions
ature, and the marginal cost for each decision point
in each cohort. Whereas the means and interquartile ranges
was determined from our institutional cost data. The
differ between these two cohorts, there is adequate overlap
Monte Carlo simulation forecasted the cost to the hospi-
of each cohort’s probability distribution, which helps ac-
tal of providing care for TEVAR patients and for open
count for how our single-institution data deviated from
TAA repairs. Forecasts were generated for the index hos-
our multi-institutional forecasts.
pitalization, postintervention year 1, and postinterven-
Our sensitivity analysis revealed that the primary cost
tion year 3.
drivers of TEVAR were (in order) in-hospital cost of an un-
The output of the Monte Carlo simulation predicted
complicated procedure, rate of respiratory complications,
that the average cost for index hospitalization for TEVAR
and rate of paralysis. Reintervention rate was much lower
would be lower than for open repair ($48,006 vs $55,109;
on the hierarchy. In looking at open repair, in-hospital
Fig 1). In modeling costs at 1 year and 3 years after inter-
cost of an uncomplicated procedure was also the strongest
vention, the cost gap between the two groups narrowed
driver of cost, although less significant than in TEVARs.
slightly, but TEVAR remained the less expensive alterna-
Complication rates and complication costs were stronger
tive at both time points ($51,885 vs $57,901 at 1 year,
drivers of total cost in the open group, with rate of respira-
$52,825 vs $58,426 at 3 years). Of note, these lines never
tory complications, cost of respiratory complications, rate
intersected during our 3-year forecast.
of major bleeding event, and rate of paralysis being the
The estimated cumulative cost of care incurred by the
strongest drivers.
hospital during a 3-year period for each cohort, including
a mean estimate (from Table I) around its relevant proba-
bility distribution, for all 100,000 iterations of our model is DISCUSSION
displayed in Fig 2. This figure displays a more detailed view The present study provides a midterm cost analysis of
of the output of the Monte Carlo simulation. Ultimately, TAA repair strategies using Monte Carlo simulation to
 JOURNAL OF VASCULAR SURGERY
600 Gillen et al March 2015

Table IV. Postoperative complications and outcomes

Our TEVAR (n ¼ 131), TEVAR from the literature, Our open (n ¼ 27), Open from the literature,
Outcome % (No.) mean % (range) % (No.) mean (range)

Stroke 5.3 (7) 3 (0-9.5) 0 (0) 5 (2.1-10.3)

Paralysis 2.3 (3) 2 (0-5) 0 (0) 4 (1.5-14)
Major bleeding event 2.3 (3) 0.01 (0-0.01) 0 (0) 3 (1.4-6.5)
Myocardial infarction 3.0 (4) 2.1 (2-2.3) 3.7 (1) 5 (4-6.3)
Respiratory complication 14.5 (19) 10 (4.3-16) 11.1 (3) 23 (10.4-44)
30-day mortality 5.3 (7) 3 (0-8.1) 3.7 (1) 7 (2.3-20)
Reinterventions at 1 year 13.7 (18) 10.8 (4-20) 3.7 (1) 2.9 (0-7)
Reinterventions at 3 years 17.6 (23) 13.8 (6.6-26) 11.1 (3) 4.5 (0-10)

TEVAR, Thoracic endovascular aortic repair.

a reimbursement model in which hospitals are paid a

Fig 1. Cost forecast of thoracic endovascular aortic repair
(TEVAR) vs open thoracic aortic aneurysm (TAA) repair over
time. Each forecast reflects the mean surrounded by error bars
reflecting the interquartile range.
forecast cumulative hospital costs up to 3 years after inter-
vention. In the TAA repair cohort from our institution,
there were more complications within the TEVARs
compared with the open repairs, which is the inverse of
the relationship typically observed in the literature. This
finding is likely to be at least partly explained by the milder
preoperative risk profile of our open cohort. There were
slightly more complications in our TEVARs compared
with TEVARs in the literature but substantially fewer com-
plications in our open repairs compared with the literature.
In addition, the longest length of stay in our open cohort
was 17 days, demonstrating the mild complication profile
of this group of patients. Because complications drive hos-
pital costs, it was not surprising that TEVARs had signifi-
cantly higher costs than open repairs within our cohort.
However, this cost disparity was not present in evaluating
patients who did not experience any complications, further
reinforcing the critical relationship between complications
and cost.
In the current health care market, hospitals are reim-
bursed for caring for more complex patients, even if the
patient’s complexity is related to a complication from
the procedure. Ideally, a hospital would be able to care
for a TAA patient without taking a loss. As we move to
flat rate for taking care of patients with a particular
disease, regardless of complications, maintaining low
complication rates will be paramount to maintain finan-
cial solvency.
Our Monte Carlo simulation (using complication
rates from the literature and our institution’s cost data)
predicted lower hospital costs in TEVARs during the in-
dex hospitalization as well as at 1 year and 3 years after
intervention. Considering the differences in our institu-
tion’s complication rates compared with the literature,
the reversal of this relationship compared with our insti-
tution’s raw cost data is not surprising. This discrepancy
further emphasizes the caution we should take in draw-
ing conclusions from single-institution data as they may
not reflect multi-institutional trends. However, cost
modeling with Monte Carlo simulation is one method
that may provide more accurate and generalizable infor-
mation in comparing different treatment modalities,
rather than looking at single-institution data. Monte
Carlo simulation is a well-known analytics technique
commonly used in business that uses simulations run
repetitively to generate probabilistic predictions of out-
comes. The primary caveat for Monte Carlo simulation
is that the strength and accuracy of the conclusions are
only as strong as the assumptions made in defining the
model.
On further interrogation of our institution’s cost data,
there were some interesting findings. The complication
that generated the highest increase in hospital cost was a
major bleeding event. Surprisingly, all three major bleeding
events were in our TEVAR cohort (2.3% of cases), with
none in our open repairs. Alternatively, the increased cost
associated with stroke in our data set was quite low. This
can partially be attributed to two of our stroke patients
dying in the hospital within a week of their intervention,
rather than undergoing prolonged hospital stays with
many procedures and intensive care unit readmissions,
which was the hospital course experienced by our patients
with major bleeding events.
In general, TEVARs have higher rates of endovascular
and open reinterventions compared with open TAA re-
pairs. However, these rates are not dramatically higher
JOURNAL OF VASCULAR SURGERY
Volume 61, Number 3 Gillen et al 601

Fig 2. Forecasted cumulative 3-year costs of thoracic endovascular aortic repair (TEVAR) vs open repair. The x-axis
reflects the forecasted cost ($) and the y-axis reflects probability (%). The mean, median, 25th percentile, and 75th
percentile are indicated for each forecast. Of note, the interquartile range of each forecast does not overlap.

than open reintervention rates.9,12,13,15-18,22 In addition,
the hospital cost of one surveillance chest computed to-
mography scan is $180 at our institution, so even with
frequent imaging in TEVAR patients, the cost of surveil-
lance imaging is small compared with the costs for proce-
dural interventions and complications. Consequently,
even when forecasted at 3 years, our model predicted lower
costs for TEVAR compared with open repair. Our sensi-
tivity analysis further confirmed the relatively small contri-
bution of reinterventions and imaging to total costs,
demonstrating that the cost of an uncomplicated index
procedure was the primary driver of total cost to the hospi-
tal in both TEVARs and open repairs. Therefore, the best
way for a hospital to reduce the financial burden of these
procedures is to work to reduce the index hospitalization
costs, such as by reducing length of stay or negotiating
for lower stent graft costs.
Most cost analyses of TAA repairs have analyzed hospi-
tal costs only during the index hospitalization. Some of
these studies have shown TEVAR to be less expensive
because of shorter hospital stays with lower complication
rates,10,14 whereas others have shown no difference be-
tween open and endovascular repairs.3,7 One study has
evaluated costs beyond the initial hospital stay. Karimi
et al14 evaluated their TAA cost data in a 57-patient,
single-center cohort for 2 years after intervention. They
found that in the hospital and at 2 years after intervention,
TEVAR was the more cost-effective option. Our cost
model corroborates these findings, presumably with greater
validity because of the use of data from outside of our sin-
gle institution.
Several conclusions can be drawn from this study that
will affect how we care for TAA patients. Despite the gen-
eral assumption that the cost of TEVARs over time out-
weighs the initial cost benefits, our model argues to the
contrary. Because surveillance imaging and reinterventions
are relatively low drivers of cost, TEVARs maintain an eco-
nomic advantage in our model. In addition, our institu-
tion’s data demonstrate that with appropriate selection of
patients, open TAA repair can be performed effectively
with low complication rates and low hospital costs. There-
fore, at medical centers with surgeons who are proficient at

602 Gillen et al
open aortic surgery, this treatment still remains a viable and
cost-effective option.
There are select limitations of the present analysis.
First, this is a retrospective review of our outcomes and
cost data, which comes with the inherent limitations asso-
ciated with this type of review. Second, follow-up data
were inconsistent, as some patients had no documented
visits after their hospitalization for their index procedure.
In addition, readmissions and reinterventions were
captured only if patients returned to our institution,
which likely is not the case 100% of the time. Third, the
number of each type of complication within our data set
was relatively small (particularly within our open cohort);
thus, our cost estimates associated with each complication
are subject to stronger influence by outliers. Fourth, we
performed our cost analysis from the perspective of the
hospital. However, from the perspective of the entire
health care delivery system, there are additional costs to
the system for patients who experience strokes, paralysis,
or renal failure requiring dialysis or who require discharge
to rehabilitation facilities or skilled nursing facilities.23
Finally, a higher percentage of our open cases was per-
formed earlier in our study window, as TEVAR has
become the preferred first-line treatment choice in recent
years. Therefore, our open cost data may appear artificially
low because of the effects of inflation through time.
Because our institutional rates of cost inflation were not
obtainable, we were unable to normalize our cost data
to “2012 dollars,” for instance.
CONCLUSIONS
Cost modeling with Monte Carlo simulation demon-
strated lower costs for TAA repair by TEVAR compared
with open repair at all time points up to 3 years after
intervention. Despite the widespread assumption that
TEVAR becomes relatively more expensive through
time because of higher reintervention rates and increased
surveillance imaging, our model argues against this the-
ory. Because the majority of reinterventions occur within
the first 3 years of the index procedure, it is expected that
the cost-effective dominance of TEVAR will hold
through time. Whereas our institutional data suggest
that open repair can be performed safely and cost-
effectively with appropriate selection of patients, TEVAR
should remain the preferred option for TAA repair from
the standpoint of both patient outcomes and cost-
effectiveness.
The authors would like to acknowledge the contribu-
tions of Margaret C. Tracci, MD, JD, Gorav Ailawadi,
MD, and Saher S. Sabri, MD, to the development of this
manuscript and the care of the patients used in this study.
AUTHOR CONTRIBUTIONS
Conception and design: JG, KY, KC, JK, IK, GU, CL
Analysis and interpretation: JG, KY, CL
Data collection: BS
JOURNAL OF VASCULAR SURGERY
March 2015
Writing the article: JG, KY
Critical revision of the article: JG, KY, BS, KC, JK, IK, GU,
CL
Final approval of the article: JG, KY, BS, KC, JK, IK, GU,
CL
Statistical analysis: JG, KY
Obtained funding: Not applicable
Overall responsibility: JG
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Submitted Jun 23, 2014; accepted Sep 14, 2014.

Supplementary Table. Studies assessing postoperative outcomes in thoracic aortic aneurysm (TAA) repair

Major
In-hospital Respiratory Myocardial bleeding 1-year 3-year
Authors, year Intervention No. mortality Stroke Paralysis complication infarction event reintervention reintervention

Almeida et al, TEVAR 255 0.8 3.1 6.6

2009
Arnaoutakis et al, Open 50 10 14
2011 TEVAR 50 0 4
Cheng et al, 2010 Open 5888a 13.9 6.2 4.9 33.2 6.3 6.5
TEVAR 5888a 5.8 5 1.4 11.1 2.3 0.01
Desai et al, 2012 Open 45 6.7 2.2 4.4 22 0 0
TEVAR 106 2.8 1.9 1.9 9.6 9 14
Estrera et al, 2005 Open 300 7.3 2.1 2.3 2 3
Foley et al, 2012 TEVAR 194 3.6 1.5 8.4 14.9
Geisbusch et al, TEVAR 264 18 26
2011
Glade et al, 2005 Open 53 11 4 8 28 4
TEVAR 42 5 0 2 9 2
Go et al, 2007 Open 94 11.7 7.4 7 10
TEVAR 142 2.1 3.5 0.7 7 10
Goodney et al, Open 12,573 7.1
2011 TEVAR 2732 6.1
Gopaldas et al, Open 9106 2.3 2.4 10.4
2010 TEVAR 2563 2.3 2.3 4.3
Karimi et al, 2012 Open 29 10.3 10.3 3.4
TEVAR 28 3.6 7.1 3.6
Lee et al, 2013 TEVAR 83 1.3 2.5 1.3 4 8
Matsumura et al, Open 70 5.7 8.6 5.7 44 1.4 5.7
2008 TEVAR 160 1.9 2.5 1.3 16 0 4.4
Narayan et al, Open 39 20
2011 TEVAR 45 6
Orandi et al, 2009 OPEN 1030 6.4
TEVAR 267 7.7
Parsa et al, 2011 TEVAR 51 0 0 0 20
Patterson et al, TEVAR 670 5 5 5
2013
Schermerhorn Open 2549 10 2.6 1.5 13.4
et al, 2008
Stone et al, 2006 Open 93 9.6 7.5 4.5
TEVAR 105 8.1 9.5 4.8
Zoli et al, 2010 Open 104 9.6 5.8 4.8 15.4 1 7

TEVAR, Thoracic endovascular aortic repair.

a
Total of 5888 patients in both cohorts.