Towards patient centred outcomes for elective abdominal aortic aneurysm repair: a scoping review of quality of life scales

Objective: In order to better incorporate the patient's perspective in medical decision making, core outcome sets (COS) are being defined. In the field of abdominal aortic aneurysm (AAA), efforts to capture the patient's perspective focus on generic quantitative quality of life (QoL) scales. The question arises whether these quantitative scales adequately reflect the patient's perspective on QoL, and whether they can be included in the QoL aspect of COS. A scoping review of QoL assessment in the context of elective AAA repair was undertaken.Data Sources: PubMed, Embase, Web of Science, and the Cochrane Library.Review Methods: A scoping review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines. Articles reporting QoL assessment in the context of elective AAA repair were identified. Quantitative studies (i.e., traditional QoL scales) were aligned (triangulation approach) with qualitative studies (i.e., patient perspective) to identify parallels and discrepancies. Mean Short Form 36 item survey (SF-36) scores were pooled using a random effects model to evaluate sensitivity to change.Results: Thirty-three studies were identified, of which 29 (88%) were quantitative and four (12%) qualitative. The 33 studies reported a total of 54 quantitative QoL scales; the most frequently used were the generic SF-36 (16 studies) and five dimension EuroQol (EQ-5D; eight studies). Aneurysm specific scales were reported by one study. The generic quantitative scales showed poor alignment with the patient's perspective. The aneurysm specific scales better aligned but missed "concerns regarding symptoms" and "the impact of possible outcomes/complications". "Self control and decision making", which was brought forward by patients in qualitative studies, was not captured in any of the current scales.Conclusion: There is no established tool that fully captures all aspects of the patient's perspective appropriate for a COS for elective AAA repair. In order to fulfil the need for a COS for the management of, AAA disease, a more comprehensive overview of the patient's perspective is required.Vascular Surger

Meta-analysis of long-term survival after elective endovascular or open repair of abdominal aortic aneurysm

Background: Endovascular aneurysm repair (EVAR) has become the preferred strategy for elective repair of abdominal aortic aneurysm (AAA) for many patients. However, the superiority of the endovascular procedure has recently been challenged by reports of impaired long-term survival in patients who underwent EVAR. A systematic review of long-term survival following AAA repair was therefore undertaken.Methods: A systematic review was performed according to PRISMA guidelines. Articles reporting short- and/or long-term mortality of EVAR and open surgical repair (OSR) of AAA were identified. Pooled overall survival estimates (hazard ratios (HRs) with corresponding 95 per cent c.i. for EVAR versus OSR) were calculated using a random-effects model. Possible confounding owing to age differences between patients receiving EVAR or OSR was addressed by estimating relative survival.Results: Some 53 studies were identified. The 30-day mortality rate was lower for EVAR compared with OSR: 1.16 (95 per cent c.i. 0.92 to 1.39) versus 3.27 (2.71 to 3.83) per cent. Long-term survival rates were similar for EVAR versus OSR (HRs 1.01, 1.00 and 0.98 for 3, 5 and 10 years respectively; P = 0.721, P = 0.912 and P = 0.777). Correction of age inequality by means of relative survival analysis showed equal long-term survival: 0.94, 0.91 and 0.76 at 3, 5 and 10 years for EVAR, and 0.96, 0.91 and 0.76 respectively for OSR.Conclusion: Long-term overall survival rates were similar for EVAR and OSR. Available data do not allow extension beyond the 10-year survival window or analysis of specific subgroups.Vascular Surger

Long-term Prognosis After Elective Abdominal Aortic Aneurysm Repair is Poor in Women and Men The Challenges Remain

Objective: To evaluate the impact of changes in elective Abdominal Aortic Aneurysm (AAA) management on life-expectancy of AAA patients.Background: Over the past decades AAA repair underwent substantial changes, that is, the introduction of EVAR and implementation of intensified cardiovascular risk management. The question rises to what extent these changes improved longevity of AAA patients.Methods: National evaluation including all 12.907 (82.7% male) patients who underwent elective AAA repair between 2001 and 2015 in Sweden. The impact of changes in AAA management was established by a time-resolved analysis based on 3 timeframes: open repair dominated period (2001- 2004, n = 2483), transition period (2005-2011, n = 6230), and EVAR-first strategy period (2012-2015, n = 4194). Relative survival was used to quantify AAAassociated mortality, and to adjust for changes in life-expectancy.Results: Relative survival of electively treated AAA patients was stable and persistently compromised [4-year relative survival and 95% confidence interval: 0.87 (0.85- 0.89), 0.87 (0.86- 0.88), 0.89 (0.86- 0.91) for the 3 periods, respectively]. Particularly alarming is the severely compromised survival of female patients (4-year relative survival females 0.78, 0.80, 0.70 vs males 0.89, 0.89, 0.91, respectively). Cardiovascular mortality remained the main cause of death (51.0%, 47.2%, 47.9%) and the proportion cardiovascular disease over non-cardiovascular disease death was stable over time.Conclusions: Changes in elective AAA management reduced short-term mortality, but failed to improve the profound long-term survival disadvantage of AAA patients. The persistent high (cardiovascular) mortality calls for further intensification of cardiovascular risk management, and a critical appraisal of the basis for the excess mortality of AAA patients.Vascular Surger

Response to the Comment on "Long-term Prognosis After Elective Abdominal Aortic Aneurysm Repair is Poor in Women and Men''

Vascular Surger

Hypothesis of the High Mortality of Female Patients Following Elective Open Abdominal Aortic Aneurysm Repair

Vascular Surger

A Systemic Evaluation of the Costs of Elective EVAR and Open Abdominal Aortic Aneurysm Repair Implies Cost Equivalence

Objective: The suggested high costs of endovascular aneurysm repair (EVAR) hamper the choice of insurance companies and financial regulators for EVAR as the primary option for elective abdominal aortic aneurysm (AAA) repair. However, arguments used in this debate are impeded by time related aspects such as effect modification and the introduction of confounding by indication, and by asymmetric evaluation of outcomes. Therefore, a re-evaluation minimising the impact of these interferences was considered.Methods: A comparative analysis was performed evaluating a period of exclusive open repair (OR; 1998-2000) and a period of established EVAR (2010-2012). Data from four hospitals in The Netherlands were collected to estimate resource use. Actual costs were estimated by benchmark cost prices and a literature review. Costs are reported at 2019 prices. A break even approach, defining the costs for an endovascular device at which cost equivalence for EVAR and OR is achieved, was applied to cope with the large variation in endovascular device costs.Results: One hundred and eighty-six patients who underwent elective AAA repair between 1998 and 2000 (OR period) and 195 patients between 2010 and 2012 (EVAR period) were compared. Cost equivalence for OR and EVAR was reached at a break even price for an endovascular device of (sic)13 190. The main cost difference reflected the longer duration of hospital stay (ward and Intensive Care Unit) of OR ((sic)11 644). Re-intervention rates were similar for OR (24.2%) and EVAR (24.6%) (p = .92).Conclusion: Cost equivalence for EVAR and OR occurs at a device cost of (sic)13 000 for EVAR. Hence, for most routine repairs, EVAR is not costlier than OR until at least the five year follow up.Vascular Surger