"Textbook Outcome" in Endovascular Aortic Repair is Associated With Improved One-year Survival.

OBJECTIVE

To determine the association of achieving a textbook outcome (TO) in endovascular aortic repair (EVAR) on 1-year mortality and identify risk factors associated with failure to achieve at TO.

BACKGROUND

TO has been described as a composite measure of the most desirable surgical outcome. The association of TOs with survival and risk factors associated with failing to achieve a TO have not been previously examined for EVAR, thoracic EVAR (TEVAR), or fenestrated/branched (complex) EVAR (cEVAR).

METHODS

The vascular quality initiative registries for EVAR (2003-2023), TEVAR, and cEVAR (2011-2023) were queried for elective cases performed for aneurysmal disease. TO was defined as freedom from major postoperative complications, perioperative reintervention/mortality, prolonged length of stay, and discharge to previous residence. TO and non-TO patient demographics, postoperative outcomes, and 1-year survival were analyzed. Regression analysis was performed to define variables associated with failure to achieve a TO.

RESULTS

TO was achieved in 53,008 (77.6%), 2276 (69.3%), and 3306 (61.1%) of EVAR, TEVAR, and cEVAR procedures, respectively. Kaplan Meier estimates of 1-year survival were significantly higher for all TO patients versus non-TO [EVAR: 96.3 ± 0.1% vs 87.0 ± 0.6%; TEVAR: 94.2 ± 1.2% vs 78.3 ± 2.7%; cEVAR: 94.8 ± 1.0% vs 82.0 ± 2.0% (P < 0.001)]. Achieving a TO was the most protective factor against 1-year mortality when adjusting for other covariates on Cox regression analysis [EVAR hazard ratio (HR): 0.36; 95% CI: 0.33-0.39, TEVAR HR: 0.27; 95% CI: 0.27-0.35. cEVAR HR: 0.24; 95% CI: 0.20-0.30, all P < 0.001]. Common factors associated with failure to achieve TO after multivariable adjustment included age >75 years, preoperative creatinine>1.7 mg/dL, female sex, congestive heart failure, and dependent functional status (all, P < 0.05).

CONCLUSIONS

Failure to achieve TO in EVAR, TEVAR, and cEVAR is associated with 1-year mortality. This association demonstrates the importance of patient selection, perioperative optimization, and processes of care. As such, it represents a comprehensive composite metric incorporating the priorities of both patients and physicians and may be useful for guiding quality improvement efforts.