A study of a new less invasive technology to prevent rupture of aortic aneurysm (a swelling in the largest artery in the body, the aorta) has found better early survival, when compared with the standard open surgery method but equivalent survival in the long-term, with higher costs from re-interventions aimed at protecting against rupture.
These are the findings of research published by the National Institute for Health Research, Health Technology Assessment (NIHR HTA) programme. The open repair method is a 60 year old tried and trusted surgical treatment but it is a major operation which involves a relatively long stay in hospital and a risk of mortality. In some cases, frail patients are not considered fit enough for the open repair operation as it may be too much of a strain on their body and requires a general anaesthetic. EndoVascular Aneurysm Repair (EVAR) was developed in the early 1990s. It is a minimally invasive technique and generally involves a shorter stay in hospital and can be performed under local anaesthesia. The Vascular Surgery Research Group, led by Professor Roger Greenhalgh of Imperial College London, has been conducting EndoVascular Aneurysm Repair trials since recruitment commenced in 1999. For EVAR Trial 1, the results showed that survival within 30 days of the operation was better (1.7% risk of death rather than 4.7% for open repair) in patients that had the EVAR operation. However, during a follow-up to 10 years, other causes of death, including rupture of the implanted EVAR graft, increased such that, overall, there was no significant difference between the two groups in the rate of death from the aneurysm or any other cause in the longterm. Rates of graft-related complications and re-interventions were much higher in the patients treated with EVAR, and new complications continued to occur, requiring regular surveillance and correction, contributing to higher costs. Professor Greenhalgh commented: “Longterm follow-up of a new method against the old is vital. Here, the less invasive popular procedure is promising, but requires regular follow-up to spot imminent risk of possible rupture and steps taken to avoid this.” For EVAR Trial 2, patients undergoing EVAR experienced a lower risk of aneurysm-related mortality than those who had been left untreated in the long-term, but this did not appear to increase their survival as illnesses, other than their aneurysm, contributed to a high rate of death overall. Professor Greenhalgh commented: “In such very unfit patients, EVAR treatment does not save lives, raises hopes, and is not cost-effective. However, once a diagnosis of large aortic aneurysm is known to patient and doctor, it proves difficult to withhold this new treatment. Management of underlying illnesses should be the first priority.”
