O-007 - AN ANALYSIS OF COST EFFECTIVENESS AND CLINICAL OUTCOMES OF A COMPREHENSIVE AORTIC SERVICE IN A TERTIARY CENTRE OVER ONE YEAR

TOPIC:
Abdominal Aortic Aneurysms
AUTHORS:
Songra L. (Royal Free Hospital, Department of Vascular Surgery ~ London ~ United Kingdom) , Hynes N. (CÚRAM, SFI Research Centre for Medical Devices, Biomedical Sciences, National University of Ireland Galway ~ Galway ~ Ireland) , Baker D. (Royal Free Hospital, Department of Vascular Surgery ~ London ~ United Kingdom) , Davis M. (Royal Free Hospital, Department of Vascular Surgery ~ London ~ United Kingdom) , Constantinou J. (Royal Free Hospital, Department of Vascular Surgery ~ London ~ United Kingdom) , Hamilton H. (Royal Free Hospital, Department of Vascular Surgery ~ London ~ United Kingdom) , Agu O. (Royal Free Hospital, Department of Vascular Surgery ~ London ~ United Kingdom)
Introduction:
Endovascular aortic repair (EVAR) is an established and attractive alternative to open surgical repair (OSR) of abdominal aortic aneurysms (AAA) due to its superior short-term safety profile. However, opinions are divided regarding its long-term cost effectiveness. We retrospectively compared the total costs of running EVAR and OSR services in a single tertiary centre over a 12 month period, to determine whether fenestrated EVAR broadens the range of treatment options available to patients, while at the same time representing an affordable, clinically efficacious option in aortic repair.
Methods:
A single centre retrospective review was performed on 107 patients undergoing a procedure related to index or previous aortic repair in a tertiary centre. Data was collected retrospectively from the national vascular registry and hospital records. Patients were followed up for one year post operatively. The primary outcome was cost per QALY across the service for each surgical repair option. Secondary outcomes were calculated with relation to elective index AAA repair procedures, and included cost per QALY, 30-day mortality and morbidity, aneurysm-related mortality, re-intervention rates, length of hospital stay and all cause mortality at one year.
Results:
The average cost per QALY of all cases related to fenestrated endovascular aortic repair was £16,041.53 (+/- £8,857.54), £13,893.51 (+/- £21,425.25) for standard infrarenal endovascular aortic repair, and £15,357.22 (+/- £15,904.49) for OSR (FEVAR vs EVAR p= 0.550, FEVAR vs OSR p = 0.834, OSR vs EVAR = 0.760). The cost per QALY of elective primary AAA repair was significantly lower for OSR compared to FEVAR. The cost per QALY for FEVAR was £19,134.75 (+/- 7,631.27), £15,408 (+/- 25,144.35) for EVAR, and £12,118.16 (+/- 5,437.23) for OSR (FEVAR vs EVAR p = 0.438, FEVAR vs OSR p= 0.001, EVAR vs OSR p= 0.589). There was no significant difference in 30-day or one-year mortality between the groups for elective primary repair. 30-day mortality was 9.68% (3/31) in the FEVAR cohort, and 0% in the OSR and EVAR groups (p = 0.248 vs EVAR, p = 0.288 vs OSR. One year mortality was 9.68% (3/31) for FEVAR, 5.56% (1/18) for OSR and 0% for EVAR (FEVAR vs EVAR p = 0.248 , FEVAR vs OSR p= 1, OSR vs EVAR p=0.429). Patients undergoing OSR has significantly higher respiratory morbidity of 38.9% (7/18 patients) (FEVAR 0% (0/31) p <0.001, EVAR 4.2% (1/24) p = 0.013) and a longer length of stay in ITU and hospital compared to EVAR or fenestrated EVAR. The average LOS for OSR was 11.94 days (+/- 4.82) vs 5.19 days (+/-3.78) for fenestrated EVAR and 5.71 days (+/- 13.16) for EVAR (OSR vs FEVAR p=< 0.001, OSR vs EVAR p = 0.063, FEVAR vs EVAR p = 0.836). The average ITU stay for patients undergoing OSR was 3.11 days (+/- 2.68) vs 1.84 days (+/- 1.88) for fenestrated EVAR patients vs 2.46 (+/- 12.0) days for EVAR patients ( OSR vs FEVAR p = 0.057, OSR vs EVAR p = 0.823, FEVAR vs EVAR p = 0.778). Patients who underwent FEVAR had a higher re-intervention rate within one year compared to OSR and simple EVAR (FEVAR 5/31(16.1%) vs OSR 0/18 (0%), p = 0.143, FEVAR vs EVAR 2/24 (8.3%) p= 0.451, EVAR vs OSR p = 0.498).

Conclusion:
Fenestrated EVAR, standard EVAR and OSR all represent cost effective options for aortic repair, with similar perioperative outcomes. Our data highlights the potential for fenestrated EVAR to present a viable alternative to open aortic repair, particularly in higher risk groups, when performed in specialist centres. However it remains to be seen if fenestrated EVAR presents a clinically and cost effective option in the longer term, mirrored by NICE recommendations to perform fenestrated EVAR in a RCT setting only.