Clinical efficacy and cost per quality-adjusted life years of pararenal endovascular aortic aneurysm repair compared with open surgical repair

Purpose: 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. Conclusion: 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.