title: Clinical efficacy and cost per quality-adjusted life years of pararenal endovascular aortic aneurysm repair compared with open surgical repair.
abstract: OBJECTIVE
  To gauge the efficacy of applying commercially-available endografts to pararenal endovascular abdominal aortic aneurysm (AAA) repair compared with open surgical repair (OSR).
  
  
  METHODS
  From 2001 to 2009, 1868 AAA patients were referred to our service for evaluation; of these, 118 patients had pararenal AAAs. Sixty-six patients (51 men; mean age 70.8±7.6 years) had OSR and 52 (44 men; mean age 74.3±7.2 years) underwent pararenal endovascular aneurysm repair (EVAR). The pararenal EVAR patients were older (74.3 versus 70.8 years, p = 0.014), with higher mean comorbidity severity scores (p = 0.0001). Mean aneurysm diameter was larger in the OSR patients (6.6 versus 5.9 cm, p = 0.01). Primary endpoints were aneurysm-related survival and cost per quality-adjusted life years (QALY). Secondary endpoints included 3-year freedom from major adverse clinical events, all-cause mortality, and secondary intervention.
  
  
  RESULTS
  There was no perioperative mortality in the pararenal EVAR group versus 3 (4.5%) deaths among the OSR patients (p = 0.122). The 15% 30-day morbidity with pararenal EVAR was half that of OSR (p = 0.059). Mean follow-up was 28.8 ±21.6 months for pararenal EVAR and 35.7±23.2 months for OSR. There were no aneurysm ruptures in either group and no conversions to open repair in the pararenal EVAR group. Three-year aneurysm-related survival was significantly higher with pararenal EVAR (100%) versus OSR (92.4%, p = 0.045), but the freedom from any-cause death was lower with pararenal EVAR (57.1%) than OSR (84.8%, p = 0.195). Three-year freedom from secondary intervention (pararenal EVAR 83.4% versus OSR 95.5%, p = 0.301) and all-cause survival (pararenal EVAR 57.1% versus OSR 84.8%, p = 0.195) were similar. Over a 3-year period, pararenal EVAR costs (including follow-up and reintervention) averaged €20,375 per patient to give a QALY value of 0.90, while mean costs for OSR were €23,928 per patient (0.86 QALY). The incremental cost-effectiveness ratio for pararenal EVAR was €129,586 saved per QALY gained.
  
  
  CONCLUSIONS
  Pararenal EVAR afforded patients longer quality-adjusted time without symptoms or toxicity and superior freedom from major adverse events up to 3 years. Although the relatively low 3-year survival rate reflected the greater comorbidity of the EVAR patients, pararenal EVAR was cost-effective.
authors.affiliation: Western Vascular Institute, Department of Vascular and Endovascular Surgery, University College Hospital Galway, Newcastle Road, Galway, Ireland. sherif.sultan@hse.ie
authors.forename: Sherif
authors.initials: S
authors.lastname: Sultan
authors.forename: Niamh
authors.initials: N
authors.lastname: Hynes
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000704:Analysis of Variance; D017544:Aortic Aneurysm, Abdominal / Q000175:diagnosis / Q000191:economics / Q000401:mortality / Q000601:surgery*; D001027:Aortography / Q000379:methods; D001807:Blood Vessel Prosthesis / Q000191:economics; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000191:economics* / Q000295:instrumentation / Q000401:mortality; D003362:Cost-Benefit Analysis; D057510:Endovascular Procedures / Q000009:adverse effects / Q000191:economics* / Q000295:instrumentation / Q000401:mortality; D005260:Female; D017721:Hospital Costs; D006801:Humans; D007494:Ireland; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D016016:Proportional Hazards Models; D011474:Prosthesis Design; D019057:Quality-Adjusted Life Years; D012086:Reoperation; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D015607:Stents / Q000191:economics; D015996:Survival Rate; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D018616:Ultrasonography, Doppler, Duplex