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Objectives: Thoracic endovascular aneurysm repair (TEVAR) is commonly performed by interventional radiologists, cardiologists, general surgeons, cardiothoracic surgeons, and vascular surgeons, with each specialty having differences in residency structure, operative experience, and subspecialty training. The aim of this study is to evaluate the impact of surgeon specialty on outcomes following TEVAR.
Methods: Patients who underwent TEVAR were identified from the 2007-2009 Nationwide Inpatient Sample (NIS). Physician identifiers in the NIS were used to determine surgical specialty and operative experience. Multivariate analysis adjusted for surgeon experience and mortality risk was used to compare differences in demographics, complications, outcomes, and hospital covariates.
Results: A total of 2,531 TEVAR cases were completed during the study period, of which 73.8% were completed by vascular surgeons, 15.8% by cardiothoracic surgeons, 8.0% by interventional radiologists, and the remainder by interventional cardiologists and general surgeons. Interventional cardiologists and general surgeons had too low of a sample size for valid statistical analysis. Interventional radiologists had significantly more elective cases (77.8%, P<0.001) than cardiothoracic surgeons (47.2%) or vascular surgeons (53.8%), but had a significantly higher rate of stroke (7.6% vs. 1.1%, P<0.001), cardiac events (7.2% vs. 3.6%, P<0.001), respiratory complications (4.8% vs. 1.9%, P<0.001), vascular complications (7.5% vs. 2.6%, P<0.01), and surgical site infection (2.8% vs. 0.8%, P<0.01). Despite these complications, length of stay (10.7 days) and median costs ($52,156) were similar across the three specialties. Cardiothoracic surgeons completing TEVAR have the highest mortality rate (8.6% vs. 2.6%, P<0.01). Vascular surgeons have a low stroke rate (1.1%, P<0.05 vs. interventional radiologists) and lower rate of cardiac events (3.6% vs. 6.1%, P<0.01) despite caring for patients with higher DRG mortality scores (3.6 vs. 3.4, P<0.05).
Discussion: Physician specialty impacts patient outcome following TEVAR. Vascular surgeons have the lowest overall morbidity following TEVAR compared to the other specialties, and lower mortality compared to cardiothoracic surgeons. These findings may impact patient referral patterns and hospital privileges for providers.
Table I. Patient characteristics for those who underwent TEVAR by specialty.

Variable	Interventional Radiologist	Interventional Cardiologist+	General Surgeon+	Cardiothoracic Surgeon	Vascular Surgeon
Demographics
Total cases	203 (8.0%)	40 (1.6%)	20 (0.8%)	400 (15.8%)	1,868 (73.8%)
Age	62.4 +/- 20.2	49.8 +/- 23.4	38.8 +/- 11.7#	66.3 +/- 14.1	66.4 +/- 15.7#
Female gender	39.6%	49.6%	25.7%	37.5%	42.5%
Elective	77.8%#	26.5%	0.0%#	47.2%^	53.8%
DRG mortality risk	3.5 +/- 0.9	1.5 +/- 0.5	+	3.4 +/- 1.1	3.6 +/- 1.0*
DRG severity of illness	2.4 +/- 0.9	3.1 +/- 1.1	+	2.6 +/- 0.9	2.6 +/- 1.0
Complications
Bleeding	5.4%	+	+	9.1%	7.8%
Stroke	7.6%#	+	+	0.0%*	1.1%*
Cardiac	7.2%*	+	+	6.1%	3.6%^
Respiratory	4.8%^	+	+	1.2%	1.9%
Vascular	7.5%#	+	+	2.4%	2.6%
SSI	2.8%^	+	+	0.0%	0.8%
Other	0.0%	+	+	0.0%	0.2%
Outcomes
Length of stay (days)	10.7 +/- 14.1	15.1 +/- 14.4	27.7 +/- 16.0#	9.3 +/- 10.3	10.1 +/- 13.2
Costs	$52,156	$72,447	$52,742	$45,120	$46,450
Mortality	2.6%	+	+	8.6%^	5.5%
Hospital Covariates
Urban location	100%	100%	100%	100%	96.3%^
Teaching hospital	59.7%#	100%	100%	87.5%	84.3%

⁺ Insufficient sample size; data do not accurately represent population-level estimates. * P<0.05; ^ P<0.01, ^# P<0.001.