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Rule of four: an anatomic and value-based approach to stent-graft inventory for blunt thoracic aortic injury
Kristofor A Olson1, C Yvonne Chung2,3, Nikolas O Aksamit4
1Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, 1500 Red River Street, Annex, Austin, TX, 78701, USA. kris.olson@utexas.edu.
Insights
Optimizing thoracic endovascular aortic repair (TEVAR) inventory for blunt thoracic aortic injury (BTAI) is crucial. A study found that just four stent-graft sizes can successfully treat all BTAI patients, reducing logistical challenges.
Area of Science:
- Vascular Surgery
- Trauma Management
- Medical Device Logistics
Background:
- The shift towards thoracic endovascular aortic repair (TEVAR) for blunt thoracic aortic injury (BTAI) presents inventory challenges.
- Managing diverse stent-graft sizes involves significant storage, shelf-life, and cost considerations.
Purpose of the Study:
- To test the hypothesis that a limited range of stent-graft sizes can effectively treat most BTAI cases.
- To propose a value-based, anatomic approach for optimizing institutional stent-graft inventory.
Main Methods:
- CT scans of 28 BTAI patients were analyzed for aortic measurements.
- Twenty commercially available stent-graft sizes were evaluated.
- MATLAB was used to identify the optimal combination of stent-grafts to cover the maximum patient cohort.
Main Results:
- A cohort of 28 BTAI patients was analyzed, with 25 meeting inclusion criteria.
- A combination of only four stent-graft sizes was found to be sufficient for 100% of the analyzed patient cohort.
- This limited inventory approach demonstrated high coverage for BTAI treatment.
Conclusions:
- An inventory of four specific stent-graft sizes can effectively treat 100% of patients with BTAI based on anatomical measurements.
- This finding supports a value-based strategy for creating and maintaining institutional stent-graft inventories.
- Optimized inventory reduces logistical burdens and potentially improves cost-effectiveness in BTAI management.
Purpose:
As blunt thoracic aortic injury (BTAI) treatment has shifted from open to thoracic endovascular aortic repair (TEVAR), logistical challenges exist in creating and maintaining inventories of appropriately sized stent-grafts, including storage demands, shelf-life management and cost. We hypothesized that most injured aortas can be successfully repaired with a narrow range of stent-graft sizes and present a value-based anatomic approach to optimizing inventory.
Methods:
CT-scans of all patients with BTAI admitted to our Level I trauma center from Apr 2010-Dec 2018 were reviewed. Patients with anatomy incompatible with TEVAR were excluded. For each patient, after aortic sizing a set of two stent-grafts most likely to be utilized was selected from a list of twenty commercially available GORE conformable TAG endografts based on manufacturer instructions. Stent-graft sizes were then ranked based on the number of cases they would be suitable for. MATLAB was utilized to determine the combinations of stent-grafts which would cover the most patients.
Results:
Twenty-eight patients with BTAI were identified and three were excluded based on iliac diameter. Most patients were male (68%), mean age 42.3 ± 20.2 years, mean ISS 37.0 ± 9.8. Overall mortality was 25%. Of the 20 available stent-graft options, a combination of four stent-grafts would successfully treat 100% of the patients in this series.
Conclusions:
Based on actual CT-scan aortic measurements, we demonstrated that an inventory of four sent-graft sizes was sufficient to treat 100% of patients with BTAI. These data can be utilized as a value-based anatomic approach to aortic stent-graft institutional inventory creation and maintenance.
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