“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.