French report ‘justifies’ reimbursement for TEVAR

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At the Multidisciplinary European Endovascular Therapy (MEET) congress in Cannes, France, Dr Patrice Bergeron, St Joseph’s Hospital, Marseille, France, stated that a French review of the literature found that thoracic endovascular aortic repair (TEVAR) has a high-enough success rate and low-enough mortality and morbidity to justify reimbursement by the French Health Authority.

According to the report, TEVAR had a technical success rate of 94.5% and a surgical conversion rate of only 1.4%, and the average hospital stay was 6.6 days. It was also reported that 7.5% of patients experienced late endoleaks at an average follow-up of almost 18 months.

Bergeron explained that the review, which was undertaken by the French Society of Vascular Surgery, involved a detailed examination of 58 publications on TEVAR. All the studies involved industrial stent grafts, and all involved the descending aorta or the aortic arch. To be included, the study had to have involved at least 30 patients if they were being treated for a thoracic aortic aneurysm and a thoracic aortic dissection, at least 20 patients if they were being treated for a thoracic aortic aneurysm or a thoracic aortic dissection, or at least ten patients if they were being treated for trauma, intramural haematoma, or a penetrating atherosclerotic ulcer.

Also assessed by the expert panel reviewing the studies, were four studies comparing stent grafting to surgery, and one study comparing stent grafting to drug therapy. Unfortunately, the experts concluded that these comparative studies were of poor scientific quality and did not allow for reliable comparisons between groups of patients.

Following this, Bergeron briefly discussed a separate study comparing TEVAR to open repair that appeared too late to include in the French review. This study found that operative mortality with TEVAR was 7.6%, compared with 15.1% for open repair (Journal of Vascular Surgery 2006;44:1188-97). The French report concluded that the indications for stent grafting are the same as for open surgery, namely aneurysms more than 6cm in diameter with a proximal neck of at least 2cm in length, complicated or symptomatic dissections, and complicated penetrating ulcers. They noted a particular benefit in poly-traumatic patients.

Combined results from 11 studies and 921 patients indicated that the 30-day mortality for elective TEVAR was 5.9%, compared with 16% for emergency TEVAR. Seven studies involving 318 patients showed a global mortality of 13.3% for elective TEVAR and 28.2% for emergency TEVAR.

The authors of the report recommended that centres intending to perform TEVAR have both stent-grafting and surgical expertise as well as proper technical equipment. They said that it was appropriate that stent grafting be used in both public and private centres as long as multidisciplinary decision making was carried out. They said that patients must be informed of the advantages and disadvantages of both techniques, and they should be followed up annually with a plain x-ray plus either a CT scan or an MRI.

Whereas costs can be reimbursed in the United States, TEVAR is not yet approved for reimbursement in most of Europe.