Key result
EVAR is linked to ~54 months longer median overall survival versus conservative management in unfit patients.
Why the study?
The EVAR-2 trial suggested EVAR failed to provide an overall survival advantage over conservative management in patients unfit for open surgical repair, prompting comparison in patients with poor CPET metrics.
Does endovascular aneurysm repair improve overall survival compared to conservative management in patients with abdominal aortic aneurysm who are physiologically unfit for open surgical repair?
Cohort (n=350)
No
Does endovascular aneurysm repair improve overall survival compared to conservative management in patients with abdominal aortic aneurysm who are physiologically unfit for open surgical repair?
Absolute Event Rate: 84% vs 30%
p-value: p=<.001
EVAR provides a substantial survival advantage and is highly cost-effective for AAA patients physiologically unfit for open surgical repair, challenging previous guidance based on the EVAR-2 trial.
May support EVAR in unfit AAA patients; leaves open whether RCTs should confirm benefit before changing practice.
OBJECTIVE: The endovascular aneurysm repair-2 (EVAR-2) trial suggested that EVAR in patients unfit for open surgical repair (OSR) failed to provide a significant overall survival advantage compared with conservative management. The aim is to compare survival and cost-effectiveness in patients with poor cardiopulmonary exercise test (CPET) metrics who underwent EVAR or were managed conservatively. METHODS: A prospective database of all CPETs (1435 patients) performed to assess preoperative fitness for abdominal aortic aneurysm repair was maintained. A total of 350 patients deemed unfit for OSR underwent EVAR or were managed conservatively. A 1:1 propensity-matched analysis incorporating age, gender, anaerobic threshold, and aneurysm size was used to compare survival. Cost-effectiveness analysis was based on the economic model for the National Institute for Health and Care Excellence clinical guideline on abdominal aortic aneurysm treatment. RESULTS: Propensity matching produced 122 pairs of patients in the EVAR and conservative management groups. The median overall survival for the EVAR group was significantly longer than that for the conservative management group (84 vs 30 months, P < .001). One-, three-, and five-year mortality in the EVAR group was 7%, 40%, and 68%, respectively, compared with 25%, 68%, and 82% in the conservative management group, all P < .001. The increment cost-effectiveness ratio for EVAR was £8023 (US$11,644) per quality-adjusted life year gained compared with £430,602 (US$624,967) in the National Institute for Health and Care Excellence guideline, which is based on EVAR-2 results. CONCLUSIONS: EVAR offers a survival advantage and is cost-effective in selected patients deemed unfit for OSR based on CPET compared with conservative management.
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Shahin et al. (2022) conducted a cohort in Abdominal aortic aneurysm in patients physiologically unfit for open surgical repair (n=350). Endovascular aneurysm repair (EVAR) vs. Conservative management was evaluated on Median overall survival (months) (p=<.001). Endovascular aneurysm repair significantly prolonged median overall survival to 84 months compared with 30 months for conservative management in patients unfit for open surgical repair.
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