Sage Journals: Discover world-class research

Abstract

Purpose:

To report the results of a trial comparing endovascular aneurysm repair (EVAR) to open repair (OR) and best medical therapy (BMT) involving high-risk patients with abdominal aortic aneurysms (AAA) suitable for EVAR.

Methods:

From 2002 to 2007, 1083 patients with aortic aneurysm disease were referred to a tertiary care university hospital. Of these, 162 (119 men; mean age 76 years) were high-risk patients with AAAs anatomically suitable for EVAR. Following comprehensive consultation with the patient, the family, and the primary physician, elective treatment was selected: OR (n=52), EVAR (n=66), or BMT (n=44). Outcomes were compared using Kaplan-Meier survival analyses and a parameter that measured the quality time spent without symptoms of disease or toxicity of treatment (Q-TWIST).

Results:

Four-year freedom from aneurysm-related death following EVAR (96.7%) was markedly better compared to BMT (66.8%; p=0.002) and was similar to OR (93.9%, p=0.483). Four-year freedom from major adverse clinical events was significantly better with EVAR (78%) compared with BMT (28%; p=0.001) and was equivalent to OR (75%; p=0.519). The 4-year intervention-free survival rate for EVAR (95%) almost matched OR (98%; p=0.410). At 4 years, Q-TWIST was 3.64 years for EVAR patients, 3.60 years for OR, and 2.22 years for BMT. Q-TWIST significantly improved with EVAR compared to OR (p<0.003). In the cost analysis, 52 high-risk patients were treated with OR over the 5-year period (2002–2007) at a total inpatient cost of €1,257,457. The 66 patients treated with EVAR (14 patients more than OR) incurred a lower cost of €1,129,138. Including the cost of follow-up over 4 years, the mean cost per patient was €18,476 for EVAR and €24,252 for OR, a savings of €5,776 per patient treated with EVAR.

Conclusion:

In high-risk patients, EVAR reduces aneurysm-related death compared to BMT. Equated to the gold standard of open repair, EVAR, as a “one-time procedure,” substantially reduces operative morbidity, hospital stay, costs, and utilization of intensive care facilities if performed in a high-volume center.

Keywords

abdominal aortic aneurysm high-risk patient endovascular aneurysm repair open repair comparative study cost analysis

Get full access to this article

View all access options for this article.

References

Parodi

Palmaz

Barone

. Transfemoral intraluminal graft implantation for abdominal aortic aneurysms. Ann Vasc Surg. 1991; 5: 491–499.

Prinssen

Verhoeven

Buth

. A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms. N Engl J Med. 2004; 351: 1607–1618.

EVAR trial participants. Endovascular aneurysm repair versus open repair in patients with abdominal aortic aneurysm (EVAR trial 1): Randomised controlled trial. Lancet. 2005; 365: 2179–2186.

EVAR trial participants. Endovascular aneurysm repair and outcome in patients unfit for open repair of abdominal aortic aneurysm (EVAR trial 2): Randomised controlled trial. Lancet. 2005; 365: 2187–2192.

Sicard

Zwolak

Sidawy

. Endovascular abdominal aortic aneurysm repair: Long-term outcome measures in patients at high-risk for open surgery. J Vasc Surg. 2006; 44: 229–236.

Bush

Johnson

Hedayati

. Performance of endovascular aortic aneurysm repair in high-risk patients: Results from the Veterans Affairs National Surgical Quality Improvement Program. J Vasc Surg. 2007; 45: 227–235.

Chaikof

Fillinger

Matsumura

. Identifying and grading factors that modify the outcome of endovascular aortic aneurysm repair. J Vasc Surg. 2002; 35: 1061–1066.

Sultan

Moore

Shanik

. Endoluminal stent grafts in the management of infrarenal abdominal aortic aneurysms: A realistic assessment. Eur J Vasc Endovasc Surg. 2001; 21: 70–74.

Dorros

Parodi

Schonholz

. Evaluation of endovascular abdominal aortic aneurysm repair: Anatomical classification, procedural success, clinical assessment, and data collection. J Endovasc Surg. 1997; 4: 203–225.

10.

Oaikhinan

Sultan

. An observational parallel group comparative study with and without the “Magic Bullet” (MB: Aspirin, cardio selective beta-blocker, Pravastatin and Clopidogrel) in the perioperative and postoperative period for abdominal aortic aneurysms surgery and femoral-popliteal segment revascularisation. Does the “Magic Bullet” improve the 30-day morbidity and mortality outcome? Br J Surg. 2004; 91: 113–114.

11.

Hynes

Koh

Sultan

. Abdominal aortic aneurysm repair in octogenarians versus younger patients in a tertiary referral center. Vascular. 2005; 13: 1–11.

12.

Gelber

Gelman

Goldhirsh

. A quality-of-life-orientated endpoint for comparing therapies. Biometrics. 1989; 45: 781–795.

13.

Bowen

De Rose

Hopkins

. Systematic review and cost-effectiveness analysis of elective endovascular repair compared to open surgical repair of abdominal aortic aneurysms. Interim Report for the Ontario Ministry of Health and Longterm Care. Hamilton, ON: Program for Assessment of Technology in Health, McMaster University; July 2005.

14.

Kertai

Boersma

Klein

. Optimizing the prediction of perioperative mortality in vascular surgery by using a customized probability model. Arch Intern Med. 2005; 165: 898–904.

15.

Glasziou

Cole

Gelber

. Quality adjusted survival analysis with repeated quality of life measures. Stat Med. 1998; 17: 1215–1229.

16.

Finkler

Ward

. Cost Accounting for Health Care Organizations: Concepts and Applications, 2nd ed. Gaithersburg, MD: Aspen Publishers; 1999.

17.

West

Balas

West

. Contrasting RCC, RVU, and ABC for managed care decisions. A case study compares three widely used costing methods and finds one superior. Healthc Financ Manage. 1996; 50: 54–61.

18.

Health service costs and quality of life for early elective surgery or ultrasonographic surveillance for small abdominal aortic aneurysms. UK Small Aneurysm Trial Participants. Lancet. 1998; 352: 1656–1660.

19.

Malina

Nilsson

Brunkwall

. Quality of life before and after endovascular and open repair of asymptomatic AAAs: A prospective study. J Endovasc Ther. 2000; 7: 372–379.

20.

Geraghty

Sicard

. Abdominal aortic aneurysm repair in high-risk and elderly patients. J Cardiovasc Surg (Torino). 2003; 44: 543–547.

21.

Lee

Carter

Upchurch

. Perioperative outcomes after open and endovascular repair of intact abdominal aortic aneurysms in the United States during 2001. J Vasc Surg. 2004; 39: 491–496.

22.

Lottman

Laheij

Cuypers

. Health-related quality of life outcomes following elective open or endovascular AAA repair: A randomized controlled trial. J Endovasc Ther. 2004; 11: 323–329.

23.

Prinssen

Buskens

Blankensteijn

. On behalf of the DREAM trial participants. Quality of life after endovascular and open AAA repair. Results of a randomized trial. Eur J Vasc Endovasc Surg. 2004; 27: 121–127.

24.

Aljabri

Al Wahaibi

Abner

. Patient-reported quality of life after abdominal aortic aneurysm surgery: A prospective comparison of endovascular and open repair. J Vasc Surg. 2006; 44: 1182–1187.

25.

Blankensteijn

de Jong

Prinssen

. Two-year outcomes after conventional or endovascular repair of abdominal aortic aneurysms. N Engl J Med. 2005; 352: 2398–2405.

26.

Dias

Ivancev

Malina

. Intra-aneurysm sac pressure measurements after endovascular aneurysm repair: Differences between shrinking, unchanged, and expanding aneurysms with and without endoleaks. J Vasc Surg. 2004; 39: 1229–1235.

27.

van Marrewijk

Fransen

Laheij

. Is a type II endoleak after EVAR a harbinger of risk? Causes and outcome of open conversion and aneurysm rupture during follow-up. Eur J Vasc Endovasc Surg. 2004; 27: 128–137.

28.

Bonneux

Cleemput

Vrijens

. KCE report 23: Elective endovascular treatment of the abdominal aortic aneurysm (AAA). Brussels, Belgium: Belgium Health Care Knowledge Center; 2005.

29.

Bertges

Zwolak

Deaton

. Current hospital costs and Medicare reimbursement for endovascular abdominal aortic aneurysm repair. J Vasc Surg. 2003; 37: 272–279.

30.

Patel

Haser

Bush

. The cost-effectiveness of endovascular repair versus open surgical repair of abdominal aortic aneurysms: A decision analysis model. J Vasc Surg. 1999; 29: 958–972.

A Prospective Clinical,Economic,and Quality-of-Life Analysis Comparing Endovascular Aneurysm Repair (EVAR),Open Repair,and Best Medical Treatment in High-Risk Patients with Abdominal Aortic Aneurysms Suitable for EVAR: The Irish Patient Trial

Abstract

Purpose:

Methods:

Results:

Conclusion:

Keywords

Get full access to this article

References