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
.