Ruptured abdominal aortic aneurysms: endovascular repair versus open surgery. A decision analytic approach
This thesis describes studies on the evaluation of endovascular repair versus open surgery in patients with ruptured abdominal aortic aneurysm (AAA). In chapter 1, the rationale for this research is presented. Since in the western world, the population is aging, it is expected that the incidence of abdominal aortic aneurysms will increase and consequently, ruptured AAAs. Ruptured AAA is a life threatening condition that requires immediate intervention. The condition can be treated with endovascular repair or open surgery. Therefore, the aim of this thesis was to investigate whether endovascular repair or open surgery would be the preferred treatment in this group of patients from a decision analytic approach, taking clinical effectiveness as well as costs into account. To enable comparison of the results of endovascular repair with open surgery in patients with a ruptured AAA from the literature, it is important to systemically evaluate the published studies and to adjust for differences in inclusion criteria among the studies. In chapter 2, we performed a systematic review of studies that compared endovascular repair with open surgery in the treatment of patients with a ruptured AAA. We found that, after adjustment for patientsâ€™ hemodynamic condition upon presentation, a benefit in 30-day mortality for endovascular repair compared with open surgery for patients with a ruptured AAA was observed but was not statistically significant. In chapter 3, we compared the clinical outcomes of treatment after endovascular repair and open surgery in patients with ruptured infrarenal AAAs including one-year follow-up. It turned out that in our study with a highly selective population, mortality and morbidity might be similar for patients with a ruptured infrarenal AAA treated with endovascular repair compared with open surgery, even after one- year follow-up. In addition to the aneurysm anatomy, other criteria may be needed for endovascular repair to improve clinical outcomes. The Glasgow Aneurysm Score (GAS) is a prediction rule to predict in- hospital mortality after open surgery for patients with ruptured and unruptured AAA. The GAS, however, was developed in patients treated with open surgery only, whereas nowadays, endovascular repair is the preferred treatment for repair of ruptured AAA in many European hospitals. In chapter 4, the GAS was validated in patients with ruptured AAA treated with endovascular repair or open surgery. In addition, our aim was to modify the GAS into an updated prediction rule that predicts 30-day mortality after endovascular repair or open surgery. We found that the GAS showed limited discriminative ability in our patient population. In addition, we showed that, considering the included risk factors, 30-day mortality was always lower if patients with ruptured AAA were treated with endovascular repair instead of with open surgery. To evaluate the incurred costs of both endovascular repair and open surgery, it is important to calculate both in-hospital costs and costs during follow-up after the procedure. Chapter 5 describes the retrospectively assessment of in-hospital costs and costs of one-year follow-up of endovascular repair and open surgery in patients with an acute infrarenal AAA, using the resource utilization approach. We found that total costs including in-hospital costs and one-year follow-up in patients with acute infrarenal AAA were lower for endovascular repair than for open surgery. From a health policy perspective, it should be questioned whether current available evidence justifies todayâ€™s policy to treat patients with ruptured AAA with endovascular repair if anatomically suitable. In addition, it is of interest whether additional information is required to inform the decision making process for patients with ruptured AAA in the future. Therefore, in chapter 6, we evaluated the cost-effectiveness of endovascular repair compared with open surgery in patients with ruptured AAA and investigated whether performing future research to obtain additional information is justified. We concluded that endovascular repair was more effective and less costly compared with open surgery in patients with ruptured AAA. Therefore, current available evidence does justify todayâ€™s policy to treat patients with ruptured AAA with endovascular repair if anatomically suitable. In addition, further research is justified and should concentrate on short-term costs and clinical! effectiveness of endovascular repair versus open surgery in patients with ruptured AAA. In chapter 7 the main findings were summarized of the preceding chapters and placed in a broader context. In addition, methodological considerations and future research were discussed.
|Keywords||AAA, decision analysis, endovascular repair, open surgery, ruptured abdominal aortic aneurysms|
|Promotor||M.G.M. Hunink (Myriam)|
|Publisher||Erasmus University Rotterdam|
|Sponsor||Hunink, Prof. Dr. M.G.M. (promotor) Stichting "Lijf en Leden" W. L. Gore &Associates J.E. Jurriaanse Stichting Sanofi Winthrop Bristol-Myers V.O.F. Abbott Vascular Nycomed Nederland B.V. B. Braun Medical BV Krijnen Medical Innovations B.V.|
Visser, J.J.. (2007, November 14). Ruptured abdominal aortic aneurysms: endovascular repair versus open surgery. A decision analytic approach. Erasmus University Rotterdam. Retrieved from http://hdl.handle.net/1765/10635