Open and endovascular AAA repair have similar cost-effectiveness and survival rates

A randomized trial found that patients had similar rates of survival and quality of life whether they underwent elective open and endovascular repair of their aortic abdominal aneurysm (AAA). The procedures also had similar costs and cost-effectiveness ratios.

Lead researcher Frank E. Lederle, MD, of the Veterans Affairs (VA) Medical Center in Minneapolis, and colleagues published their results online in JAMA Surgery Sept. 14.

Each year, more than 40,000 people in the U.S. undergo elective procedures to repair their AAA, according to the researchers. They added that there are 1,250 perioperative deaths associated with AAA repair, making it the second most common cause of death among patients undergoing vascular or general surgery procedures.

In this study, known as OVER (Open vs. Endovascular Repair), the researchers enrolled 881 patients who had planned elective repair of AAA and randomized them to endovascular or open repair from Oct. 15, 2002 to April 15, 2008 in 42 VA medical centers. The mean age of the patients was 70 years old, and 99.4 percent were men.

The patients had follow-up visits one month after the aneurysm repair and six and 12 months after enrollment. They then had yearly visits. Patients undergoing endovascular repair received computed tomography and plain radiography of the abdomen during the visits. Patients undergoing open repair only had computed tomography at one year and at the end of the study.

After a mean of 5.2 years of follow-up, the mean life-years were 4.89 in the endovascular group and 4.84 in the open repair group, while the mean quality-adjusted life-years (QALYs) were 3.72 and 3.70, respectively. Neither difference was statistically significant.

The mean healthcare costs were $142,745 in the endovascular group and $153,533 in the open repair group, while the costs related to AAA accounted for nearly 40 percent of the costs in each group. Patients in the endovascular group typically had shorter hospitalization stays, but they had increased costs due to AAA-related secondary procedures and imaging studies.

Bootstrap analyses found that the probability that endovascular repair would be less costly and more effective was 56.8 percent when the researchers mentioned effectiveness in life-years and 55.4 percent when they measured it in QALYs for total costs. When measuring AAA-related costs, the probabilities were 31.3 percent and 34.3 percent, respectively.

When using total costs and a willingness to pay threshold of $50,000, endovascular repair was preferred in 88.4 percent of observations using life-years and 88.8 percent of observations using QALYs. With a willingness to pay threshold of $100,000 the proportions were 84.8 percent and 85.5 percent, respectively.

When using AAA-related costs and a willingness to pay threshold of $50,000, endovascular repair was preferred in 59.9 percent of observations using life-years and 60.7 percent of observations using QALYs. With a willingness to pay threshold of $100,000 the proportions were 62.2 percent and 64.4 percent, respectively.

The researchers cited a few potential limitations of the study, including that the VA’s accounting method might not apply to other populations. They also mentioned that their protocol was different than usual practice, including the use of computed tomography one year after open repair.

“Endovascular repair has lower perioperative mortality, shorter recovery time, and, at least in the US VA system, lower initial costs, despite the high cost of the grafts,” the researchers wrote. “However, we found that these advantages did not persist during the next 3 to 5 years. On the other hand, endovascular repair requires more long-term follow-up and carries a small risk for late rupture. Our results indicate that for patients who are candidates for both procedures, selection of either procedure remains reasonable and can be guided by patient and physician preference.”