DISCUSSION
Historically, favorable results treating thoracic aortic pathologies were restricted to centers of excellence with extensive experience in open surgical repair , limiting the access of high-quality surgical services to underrepresented populations . However, the refinement of endovascular techniques and TEVAR becoming widely available translated into better perioperative outcomes.
This contemporary study reaffirms that racial or ethnic background is not associated with in-hospital mortality after TEVAR after adjusting for hospital-level and patient-level covariates, including median household income. Instead, we observed comorbidities determining unfavorable outcomes in the multivariable analysis; white patients were more likely to be treated electively after thoracic aortic aneurysms, and black and Hispanic patients were more likely to be treated non-electively for type B aortic dissection. Most importantly, there seems to be a relative increase in the proportion of the black population having access to TEVAR technology over the last years.
Our data corresponds with previous reports. An analysis of the Vascular Quality Initiative database showed that despite increased comorbidities and advanced disease, black patients were not associated with an increased risk of perioperative complications compared to white populations (OR 0.9; 95% CI, 0.7-1.1; P = .42) . Additionally, data from 12,500 Medicare patients showed that the increased risk of perioperative mortality seen in open repairs for black patients (OR = 2.0, 95% CI1.5– 2.5, p<0.001) was offset when TEVAR was utilized compared to the white population (OR = 0.9, 95% CI=0.6–1.5, p=0.72), a relationship that remained constant across different hospital volume strata . Rather than being associated with race or ethnicity, all these studies suggest TEVAR mortality is affected by other factors such as the underlying pathologic process or clinical acuity. For example, patients with type B dissection have traditionally had lower in-hospital mortality rates than aortic aneurysms or repair of ruptured thoracic aneurysms usually have a higher risk of death than non-ruptured aneurysms.
Additionally, this analysis adds to the body of literature describing the influence of the comorbidities profile on TEVAR outcomes. For example, perioperative mortality is significantly higher in patients with chronic renal disease compared to non-renal failure patients ; chronic heart failure has been associated with TEVAR-related adjusted-mortality for both thoracic aneurysm and type B dissection ; chronic obstructive pulmonary disease has also been independently associated with increased mortality after adjusting for gender and other comorbidities (OR 4.31, CI 1.01–16.88; p=0.03) . Finally, increasing age has been identified to be interdependently associated with mortality; patients ≥80 years have higher odds for mortality than younger patients (OR, 2.32; 95% CI, 1.25 – 4.31) . In our analysis, comorbidities such as cerebrovascular disease, peripheral artery disease, and chronic kidney disease were independently associated with in-hospital mortality, reflecting the association between atherosclerosis and mortality . Worth mentioning, hypertension was associated with increased odds for hospital survival, which can be explained by hypertension being related to younger patients with Type B dissection .
Racial or ethnic disparities in health services follow a multifactorial framework; patient characteristics and preferences, surgical providers’ background, and surgical health services availability determine access to care . Thoracic endovascular grafting has demonstrated that technological advancements can effectively bridge access and outcomes gaps; namely, TEVAR made managing complex aortic pathologies simpler and safer, encouraging widespread utilization. Data from 2000 to 2012 already showed a progressive increase of thoracic endovascular aortic repair supplanting open repairs with better results . Furthermore, earlier reports even suggested that underrepresented populations (Black, Hispanic, and Native American) and patients with lower median household incomes had a higher propensity for undergoing TEVAR procedures . We could observe a relative increase in the TEVAR incidence rate during 2013 -2015 for the black population in this opportunity. This trend could be related to some national health reforms implemented during the same period. For example, the Health and Human Services Action Plan to Reduce Racial and Ethnic Health Disparities (HHS Disparities Action Plan), The Affordable Care Act insurance, and the Medicaid expansions have a temporal relationship . Likewise, it can be argued that the extension of indication criteria might have also positively impacted the underrepresented population. For example, endovascular treatment of traumatic aortic lesions could benefit minority-serving trauma centers where the uninsured population tends to cluster or the tendency to treat acute type B dissections with TEVAR may have helped the black population .