Objective
The EVAR-2 trial suggested that endovascular aneurysm repair (EVAR) in patients unfit for open surgical repair (OSR) failed to provide a significant overall survival advantage compared to conservative management. The aim is to compare survival and cost-effectiveness in patients with poor cardiopulmonary exercise test (CPET) metrics who underwent EVAR or were managed conservatively.
Methods
A prospective database of all CPETs (1435 patients) performed to assess preoperative fitness for abdominal aortic aneurysm (AAA) repair was maintained. 350 patients deemed unfit for (OSR) underwent EVAR or were managed conservatively. A 1:1 propensity-matched analysis incorporating age, gender, anaerobic threshold (AT) and aneurysm size was used to compare survival. Cost-effectiveness analysis (CEA) was based on the economic model for the National Institute for Health and Care Excellence (NICE) clinical guideline on AAA treatment.
Results
Propensity matching produced 122 pairs of patients in the EVAR and conservative management groups. The median overall survival for the EVAR group was significantly longer than the conservative management group (84 versus 30 months, p<0.001). 1, 3 and 5-year mortality in the EVAR group was 7%, 40% and 68%, respectively, compared to 25%, 68% and 82% in the conservative management group, all p<0.001. Increment cost-effectiveness ratio (ICER) for EVAR was £8,023 (US $ 11,644) per quality adjusted life year (QALY) gained compared to £430,602 (US $ 624,967) in the NICE Guideline, which is based on EVAR-2 results.
Conclusion
EVAR offers a survival advantage and is cost-effective in selected patients deemed unfit for OSR based on CPET compared to conservative management.
CORE (COnnecting REpositories)
CORE (COnnecting REpositories)