Re: Proposed NICE Abdominal Aortic Aneurysm Repair Guidelines: Swinging the Pendulum too Far?

Abstract

We welcome Dr Al Shakarchi's comment and agreement that the National Institute for Health and Care Excellence (NICE) guidelines swing the pendulum too far. Al Shakarchi raises some concerns regarding our justification for endovascular aneurysm repair (EVAR) as the standard of care for appropriate anatomies offered by the appropriate experts, emphasising the higher long term EVAR mortality and the cost effectiveness of open surgical repair (OSR), dismissing the results of the Open vs. Endovascular Repair (OVER) trial and other more contemporary large non-randomised series.1Lederle F.A. Kyriakides T.C. Stroupe K.T. Freischlag J.A. Padberg Jr., F.T. Matsumura J.S. et al.Open versus endovascular repair of abdominal aortic aneurysm.N Engl J Med. 2019; 380: 2126-2135Crossref PubMed Scopus (98) Google Scholar, 2Epstein D. Sculpher M.J. Powell J.T. Thompson S.G. Brown L.C. Greenhalgh R.M. Long-term cost-effectiveness analysis of endovascular versus open repair for abdominal aortic aneurysm based on four randomized clinical trials.Br J Surg. 2014; 101: 623-631Crossref PubMed Scopus (55) Google Scholar, 3Canning P. Tawfick W. Whelan N. Hynes N. Sultan S. Cost-effectiveness analysis of endovascular versus open repair of abdominal aortic aneurysm in a high-volume center.J Vasc Surg. 2019; 70: 485-496Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar, 4Burgers L.T. Vahl A.C. Severens J.L. Wiersema A.M. Cuypers P.W. Verhagen H.J. et al.Cost-effectiveness of elective endovascular aneurysm repair versus open surgical repair of abdominal aortic aneurysms.Eur J Vasc Endovasc Surg. 2016; 52: 29-40Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar As we stated in our letter, long term analysis of the early European randomised trials was based on few patients and was not statistically powered and did not appropriately capture re-interventions for open repair.5Patel R. Sweeting M.J. Powell J.T. Greenhalgh R.M. EVAR Trial InvestigatorsEndovascular versus open repair of abdominal aortic aneurysm in 15-years follow up of the UK endovascular aneurysm repair trial 1 (EVAR-1): a randomized controlled trial.N Engl J Med. 2010; 362: 1863-1871PubMed Google Scholar,6Van Schaik T.G. Yeung K.K. Verhagen H.J. de Bruin J.L. van Sambeek M.R.H.M. Balm R. et al.Long term survival and secondary procedures after open or endovascular repair of abdominal aortic aneurysms.J Vasc Surg. 2017; 66: 1379-1389Abstract Full Text Full Text PDF PubMed Scopus (74) Google Scholar The long term results of the OVER trial (up to 14 years) did not confirm a significant difference in mortality.1Lederle F.A. Kyriakides T.C. Stroupe K.T. Freischlag J.A. Padberg Jr., F.T. Matsumura J.S. et al.Open versus endovascular repair of abdominal aortic aneurysm.N Engl J Med. 2019; 380: 2126-2135Crossref PubMed Scopus (98) Google Scholar However, even if the long term mortality rate was true, not everyone would be willing to accept the higher OSR mortality/morbidity risk up front, just because 10 years down the line the EVAR mortality rate will match the OSR mortality rate. Regarding cost effectiveness, the OVER trial showed no difference in the cost effectiveness for OSR vs. EVAR, in contrast to the EVAR and Dutch Randomised Endovascular Aneurysm Management (DREAM) trials.2Epstein D. Sculpher M.J. Powell J.T. Thompson S.G. Brown L.C. Greenhalgh R.M. Long-term cost-effectiveness analysis of endovascular versus open repair for abdominal aortic aneurysm based on four randomized clinical trials.Br J Surg. 2014; 101: 623-631Crossref PubMed Scopus (55) Google Scholar The OVER trial is more representative of today's practice, as the recruitment period was three years after the EVAR and DREAM trials, and the length of hospital stay (and thus cost) after EVAR has been greatly reduced since the earlier trials. More recent non-randomised data confirm the long term cost effectiveness of EVAR.3Canning P. Tawfick W. Whelan N. Hynes N. Sultan S. Cost-effectiveness analysis of endovascular versus open repair of abdominal aortic aneurysm in a high-volume center.J Vasc Surg. 2019; 70: 485-496Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar,4Burgers L.T. Vahl A.C. Severens J.L. Wiersema A.M. Cuypers P.W. Verhagen H.J. et al.Cost-effectiveness of elective endovascular aneurysm repair versus open surgical repair of abdominal aortic aneurysms.Eur J Vasc Endovasc Surg. 2016; 52: 29-40Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar However, we acknowledge that caution must be exercised when transferring the results of economic evaluations from one country to another. Irrespective of these arguments, our main criticism of the NICE guideline is that by abandoning elective EVAR procedures, vascular surgeons will eventually lose their competency in performing EVAR for ruptured aortic aneurysms, despite the fact that the current evidence indicates that EVAR is superior to open repair. Re: “Proposed NICE Abdominal Aortic Aneurysm Repair Guidelines: Swinging the Pendulum too Far?”European Journal of Vascular and Endovascular SurgeryVol. 59Issue 1PreviewI read the editorial by Llapis et al.1 with great interest. The title is absolutely correct with the NICE guidelines swinging the pendulum too far. However, I was left disappointed with some of the arguments in the editorial as they swung the pendulum too far the other way. Full-Text PDF Open Archive