• S M Tomee, E Bastiaannet, M L Schermerhorn, J Golledge, J F Hamming, and J H Lindeman.
• Department of Surgery, Einthoven Laboratory for Experimental Vascular Medicine, Leiden University Medical Centre, Leiden, The Netherlands.
• Eur J Vasc Endovasc Surg. 2017 Jul 1; 54 (1): 28-33.

BackgroundThe reported 54 mm median intervention diameter for endovascular aneurysm repair (EVAR) in the Vascular Quality Initiative and European data from the Pharmaceutical Aneurysm Stabilisation Trial (PHAST) implies that in real life the majority of abdominal aortic aneurysm (AAA) repairs occur at diameters smaller than the consensus intervention threshold of 55 mm. This study explores the potential consequences of this practice.MethodsThe differences between real life AAA repair and consensus based intervention threshold were explored in reported data from vascular quality initiatives and PHAST. The subsequent consequences of advancement of endovascular aneurysm repair (EVAR) were estimated using a multistate model based on life tables for the EVAR Medicare population.ResultsThere appears an approximate 5 mm difference in AAA diameter between real life practice and consensus intervention threshold. Assuming a 2.5 mm annual growth rate, this results in an approximately 2 year advancement of AAA repair. According to the model used, early repair reduces overall small aneurysm patient mortality by 2.3%, it results in 21.9% more EVAR procedures, more EVAR related deaths, and 42.3% and 36.8% more open and endovascular re-interventions, respectively. Cost-benefit estimates imply 482 fewer AAA related deaths, but 140 extra EVAR related deaths for a population of more than 30,000 AAA patients, and a 300 million USD increase in health costs for the 8 year observation period in the Medicare population.ConclusionsIn the real life situation a large proportion of EVAR procedures appear to occur before reaching the consensus threshold. Although this reduces mortality, it comes at a cost of approximately 1 million USD per prevented rupture related death.Copyright © 2017 European Society for Vascular Surgery. All rights reserved.

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