Key result
Selective screening before elective AAA repair linked to ~38% lower 5-year mortality vs direct surgery.
Why the study?
The long-term outcomes and cost-effectiveness of selective coronary revascularization before major vascular surgery were uncertain.
Absolute Event Rate: 86% vs 77.4%
p-value: p=0.00
Supports selective screening in elective AAA repair; decision modeling leaves open need for randomized confirmation.
OBJECTIVE: To evaluate the long-term outcomes (5-year survival) and cost-effectiveness of selective coronary revascularization before major vascular surgery. DESIGN: A decision-tree model was constructed to compare the cost-effectiveness of four preoperative screening strategies from the perspective of the health care system. SETTING: Based on patient mortality, morbidity, and cost data from a literature review. PARTICIPANTS: Hypothetical cohort of patients scheduled for elective abdominal aortic aneurysm repair followed up over a 5-year period. INTERVENTIONS: Patients either proceeded directly to surgery or were screened using one of three possible preoperative screening strategies. In the first strategy, all patients were screened with a dipyridamole-thallium test. In the second strategy, all patients underwent coronary angiography. The third strategy, selective screening, first divided patients into high-, intermediate-, and low-risk groups using clinical criteria. High-risk patients underwent preoperative angiography. Intermediate-risk patients were screened noninvasively, and low-risk patients proceeded directly to surgery without further testing. MEASUREMENT AND MAIN RESULTS: Proceeding directly to vascular surgery resulted in the poorest 5-year survival rate (77.4%) compared with preoperative risk stratification followed by selective coronary revascularization, routine noninvasive testing (86.1%), selective testing (86.0%), and routine angiography (87.9%; p = 0.00). The incremental cost-effectiveness ratio for selective testing was significantly lower than for routine angiography ($44,800/years of life saved (YLS) v $93,300/YLS; p < 0.02). Routine noninvasive testing was not cost-effective. Thirty-day mortality was the same for all four strategies (p = 0.84). CONCLUSION: Selective screening before vascular surgery may improve 5-year survival and be cost-effective. Neither routine noninvasive testing nor routine angiography appears to be cost-effective compared with currently accepted medical therapies.
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Laurent G. Glance (1999) studied elective abdominal aortic aneurysm repair. Selective preoperative screening vs. Proceeding directly to surgery was evaluated on 5-year survival rate (p=0.00). Selective preoperative screening before elective abdominal aortic aneurysm repair improved 5-year survival to 86.0% compared with 77.4% for proceeding directly to surgery (p=0.00).
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