Abstract
To compare costs and effectiveness of elective open (OR) versus fenestrated/branched endovascular (ER) repair of thoracoabdominal aneurysms (TAAA) in a high-volume center. This single-center retrospective observational study (PRO-ENDO TAAA Study, NCT05266781) was designed as part of a larger Health Technology Assessment analysis. All electively treated TAAAs between 2013 and 2021 were analyzed and propensity-matched. Endpoints were clinical success, major adverse events (MAE), hospital direct costs, and freedom from all causes and aneurysm-related mortality and reinterventions. Risk factors and outcomes were homogeneously classified according to the Society of Vascular Surgery reporting standards. Cost-effectiveness value (CEV) and Incremental Cost-Effectiveness Ratio (ICER) were calculated, considering the absence of MAEs as a measure of effectiveness. Propensity matching identified 102 pairs of patients out of 789 TAAAs. Mortality, MAE, permanent spinal cord ischemia rates, respiratory complications, cardiac complications, and renal injury were higher for OR (13% vs 5%, p=.048; 60% vs 17%, p<.001; 10% vs 3%, p=.045; 91% vs 18%, p<.001; 16% vs 6%, p=.024; 27% vs 6%, p<.001; respectively). Access complication rate (6% vs 27%; p<.001) was higher in the ER group. Intensive Care Unit stay was longer (p<.001) for OR and ER patients were discharged home more frequently (3% vs 94%; p<.001). No differences in mid-term endpoints were observed at 2 years. Despite ER reducing all the hospital cost items (-42% to -88%, p<.001), the higher expenses (p<.001) of the endovascular devices increased the overall cost of ER by 80%. CEV for ER was favorable to OR (56 365 vs 64 903 €/patient) with an ICER of 48 409 € per MAE saved. ER of TAAA reduces perioperative mortality and morbidity compared to OR, with no differences in reinterventions and survival rates at midterm follow-up. Despite the expenses for endovascular grafts, ER resulted more cost-effective in preventing MAEs.
•Type of Research: single-center, retrospective analysis of prospectively collected data, comparative study with propensity score matching analysis.•Key Findings: Propensity matching identified 102 pairs out of 789 patients treated for thoracoabdominal aortic aneurysms. Mortality, major adverse events (MAE), permanent spinal cord ischemia rates, respiratory complications, cardiac complications, and renal injury were higher for open repair (OR) than for endovascular repair (ER, 13% vs 5%, p=.048; 60% vs 17%, p<.001; 10% vs 3%, p=.045; 91% vs 18%, p<.001; 16% vs 6%, p=.024; 27% vs 6%, p<.001; respectively). No differences in overall and aortic-related mortality were observed at 2 years. Despite ER reducing all the hospital cost items (-42% to -88%, p<.001), the higher expenses (p<.001) of the endovascular devices increased the overall cost of ER by 80%. Cost Effectiveness Value for ER was favourable to OR (56 365 vs 64 903 €/patient) with an Incremental Cost-Effectiveness Ratio of 48 409 € per MAE saved.•Take home Message: Despite the expenses for endovascular grafts, ER resulted more cost-effective in preventing major adverse events.