• Vascular Specialist Newspaper
• Volume 5 - 2009
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• Volume 1 - 2005
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• Number 1

HOLLYWOOD, FLA. -- Endovascular repair of thoracic aortic aneurysms is a winning strategy both clinically and economically, compared with open surgical repair. In contrast, endovascular repair of abdominal aortic aneurysms is a money-losing strategy, compared with open repair despite having several clinical advantages.

The key economic problem with endovascular repair of abdominal aortic aneurysms (AAAs) is the high cost of the endografts. The lofty price for AAA endografts "completely negates and in fact overwhelms" the economic benefits of endovascular repair that include a reduced hospital length of stay and a lower level of other hospitalization costs, Dr. Bruce A. Perler said at ISET 2009, an international symposium on endovascular therapy.

In a multivariable analysis, the average cost of an endovascular aortic aneurysm repair (EVAR) in nearly 1,400 patients treated in Maryland during 1995-2004 was about $4,600 more expensive per patient than the average cost for open surgical AAA repair in nearly 3,500 Maryland patients during the same period.

"Pressure for health care cost containment may pose limits on utilization of expensive emerging technologies such as EVAR," said Dr. Perler, professor of surgery and chief of vascular surgery at Johns Hopkins Hospital in Baltimore. This economic dilemma "may mandate reductions in the costs of [AAA] endografts" so that the cost efficacy of EVAR catches up to its clinical efficacy.

Indeed, the clinical advantages of EVAR are substantial. The same multivariate analysis of Maryland data showed that, compared with open-surgical repair, EVAR produced a 79% reduction in mortality, a 83% reduction in the need for blood transfusion, and was linked with a greater than 5-day reduction in the average length of hospitalization.

The situation for thoracic endovascular aortic aneurysm repair (TEVAR) is dramatically different. Dr. Perler cited data collected at his hospital during 1993-2005 showing that the average total cost for TEVARs was about $57,400, compared with an average of about $69,000 for each open TAA repair.

A breakdown of the costs showed that 38% of the money spent for open-repair of TAA was for hospitalization, which averaged 10 days in the ICU and a total of 18 days in the hospital. For TEVAR, the biggest expense was for the stent graft, which ate up 68% of the total cost. In the endovascular-repair group, hospitalization cost accounted for just 14% of the total, with an average of 2 days in the ICU and an overall average of 5 days in the hospital.

Dr. Perler sees the potential for an even greater edge to TEVAR in coming years because he expects that the price for TAA stent grafts will drop from their current levels.

The cost advantage for TEVAR complements its clinical benefits. Results from several reported series, as well as results from randomized trial, showed that TEVAR led to significantly reduced mortality and morbidity such as paraplegia and paraparesis, compared with open TAA repair, Dr. Perler said.

For example, in a multicenter, randomized, U.S. trial that compared 140 TAA patients who were treated with TEVAR and 94 treated with open surgery, the mortality rate within 30 days of the procedure was found to be 2% in the TEVAR group and 12% in the open-surgery group, a statistically significant difference (J. Vasc. Surg. 2006;43:A12-9). The incidence of paraplegia or paraparesis during 30-day follow-up was 3% in the TEVAR patients and 14% in the open-surgery patients.