Long-Term Survival After Endovascular Aneurysm Repair and Open Repair in Patients With Anatomy Outside Endovascular Aneurysm Repair Instructions for Use Criteria

Abstract

Objective: Percutaneous access for endovascular aneurysm repair (P-EVAR) is less invasive compared with surgical access (S-EVAR) and is associated with faster recovery and fewer wound complications. However, vascular closure devices (VCDs) are costly, and better understanding of the precise economic impact of P-EVAR has important implications for resource allocation. The objective was to determine the differences in cost between P-EVAR and S-EVAR.Methods: We used a decision tree to analyze costs from a payer's perspective during the course of the index hospitalization. Probabilities, relative risks, and mean difference summary measures were obtained from a systematic review and meta-analysis. We modeled differences in surgical site infection, lymphocele, and length of hospitalization. Cost parameters were derived from the 2014 U.S. National Inpatient Sample using International Classification of Diseases, Ninth Revision, Clinical Modification codes. Attributable costs were estimated using generalized linear models adjusted by age, sex, and comorbidities.Results: A total of 6876 abdominal and thoracic EVARs were identified. P-EVAR resulted in a cost saving of $751 per procedure. The costs were $1287 (95% confidence interval [CI], $884-$1835) for P-EVAR and $2038 (95% CI, $757-$4280) for S-EVAR. P-EVARs were converted to open repair in 4.3% of cases. P-EVAR patients had a difference of À1.4 days (95% CI, À0.12 to À2.68) in length of hospitalization at a cost of $1190/day (standard error, $298). The cost saving of P-EVAR was primarily driven by the cost difference in length of hospitalization. In the base case, four VCDs were used per P-EVAR at $200/device. In the two-way sensitivity analysis, P-EVAR was cost saving even when 1.5 times more VCDs were used per procedure and the cost of each VCD was 1.5 times greater (Fig). In our probabilistic sensitivity analysis, P-EVAR was the cost-saving strategy in 82.6% of 10,000 Monte Carlo simulations when simultaneously varying parameters across their uncertainty ranges.Conclusions: P-EVAR had lower costs compared with S-EVAR and is economically feasible.

Impact of Gradual Adoption of EVAR in Elective Repair of Abdominal Aortic Aneurysm: A Retrospective Cohort Study from 2009 to 2015

“…Furthermore, patients with IFU violations were shown to have higher overall longterm survival with open surgery compared with EVAR. 34 Moreover, for certain violations of the IFU during EVAR, such as necks with severe angulation or high thrombus load in the proximal neck, results of outside IFU seem to match the results of inside IFU, 35 and those patients might still be selected to EVAR. Second, teams may be less prepared for OSR in the EVAR era.…”

“…Open surgical and endovascular repair groups may present conditioned comparability regarding aortic anatomy, as open surgical candidates are likely to be patients who have unfavorable aortic anatomy for EVAR. 34 Only vascular reinterventions were considered in the analysis. Abdominal hernia repairs were not considered because, despite 7% (7 of 79) of patients who underwent OSR having abdominal hernia repair, these procedures were often performed in subsidiary hospitals, and the precise date could not be ascertained which precluded the use of survival analysis.…”

Exploring the boundaries of endovascular aneurysm repair

“…For example, a Canadian study showed that long-term survival after EVAR outside IFU was shorter than in patients outside IFU that underwent OR. 60 However, what this study also showed is that the EVAR group was significantly older, suffered fewer perioperative complications and had a lower 30-day mortality. Therefore, long-term benefits of OR might serve those patients who are fit enough to overcome perioperative complications, while older patients with more comorbidities might benefit from EVAR.…”

“…28,54,55 However, other studies suggested that treatment of patients outside IFU is safe. [56][57][58][59][60] Variations can be caused by the inclusion of different stent graft designs in different time periods. Possibly more important is the fact that 'outside IFU' is a broad concept.…”

“…The available evidence suggests an improved outcome, albeit limited, of balloon occlusion in very unstable rAAA patients. 59,60 One of the changes since early rAAA EVAR studies has been the configuration of the implanted stent graft. Initially AUI devices were implanted, combined with a femoral-femoral cross-over.…”