Benefit of EVAR for rAAA will be lost if elective EVAR banned

L–R: Peter Holt, Mark Field, and Max Baghai

At the first London Aorta meeting, a collaborative association between the London Aorta Masterclass and the London Aortic Symposium, held 10–11 October in London, UK, Peter Holt (St. George’s Vascular Institute in London, UK) told delegates that “patients will be unnecessarily palliated” by the UK National Institute on Health and Care Excellent (NICE) draft guidelines for ruptured abdominal aortic aneurysms (AAA). He suggested that in order to deal with this, simulation and team training will become important.

As part of a session on emergency aortic surgery, chaired by Max Baghai (King’s College Hospital NHS Foundation Trust, London, UK) and Mark Field (Liverpool Heart and Chest Hospital, Liverpool, UK), Holt began his presentation by outlining the NICE guidelines for repairing ruptured aneurysms. He delineated that NICE recommend physicians consider the following: endovascular repair (EVAR) or open surgical repair for people with a ruptured infrarenal AAA and open surgical repair for people with a ruptured complex AAA. The guidelines also suggest physicians do not offer complex EVAR to people with a ruptured AAA if open surgical repair is not suitable, except as part of a randomised controlled trial comparing complex EVAR with open surgical repair. In terms of anaesthesia and analgesia, the recommendations state that one should consider using local infiltrative anaesthesia alone for people having EVAR of a ruptured AAA.

Holt detailed that the guidelines were based on results of the IMPROVE trial, which found that EVAR had better survival rates than open aortic repair, better quality of life than open repair, a higher return home rate, and had a lower cost. Overall, EVAR dominated cost effectiveness analyses when compared to open repair.

Looking more closely at the guideline which advises physicians to consider EVAR or open surgical repair for people with ruptured AAA, Holt warned delegates: “Be aware that EVAR provides more benefit than open surgical repair for most people, especially for women and for men over the age of 70”.

In terms of epidemiology, Holt pointed out that there are certain trends that should be considered before treating ruptured AAA. Using data from Lilja et al, published in the European Journal of Vascular and Endovascular Surgery, Holt noted that there is a trend toward older patients requiring treatment, comparing an average age of 72.8 (72.3–73.3) in the period 1994–1999, to an average age of 75.3 (74.7–75.9) in the period 2010–2014. Secondly, he reported that there is an increasing number of female patients undergoing ruptured AAA surgery, with 86.3% (84.1–88.4) male patients between 1994 and 1999, compared to 79.6% (76.6–82.5) between 2010 and 2014. Also noted was the increasing age of patients, with 19.1% (16.7–21.6) of patients aged 80 years or over in the period 1994–1999 increasing to 33.3% (29.8–36.7) in the period 2010–2014. Finally, he mentioned that there is a trend towards EVAR, comprising just 0.1% (0.0–0.2) of surgeries for ruptured AAA 1994–1999, compared to 29.8% (26.5–33.2) 2010–2014.

Considering these figures, Holt stated: “It is very clear that EVAR is preferential for ruptured AAA, under local anaesthetic where possible, especially for women, and especially is the patient is over 70 years old, and most are.”

“The problem is,” he continued, “the guidelines recommend that for people with unruptured AAAs we are advised to offer open surgical repair unless there are anaesthetic of medical contraindications, do not offer EVAR to people with an unruptured infrarenal AAA if open surgical repair is suitable, and not to offer EVAR to people with an unruptured infrarenal AAA if open surgical repair is unsuitable because of their anaesthetic and medical condition.”

Holt then referred to survey results to the question “If you were not routinely performing elective EVAR in your hospital, would be able to deliver an emergency EVAR service for ruptured AAA as recommended?” Eighty-eight per cent of the respondents responded that they would not.

Considering the effects of these guidelines, Holt suggested that many unruptured elective AAA will now not be treated and will subsequently present with rupture, including NAAASP patients. He also posited that a lack of current practice will mean fewer patients awould then be offered repair and therefore would not be treated. This was on the basis that 24/7/365 service is already not reliably delivered in many hospitals, only 27% of surgeries for ruptured AAA being EVAR over the last three years, lost elective experience, and there being no consignment stock if the guidelines were to be invoked. Finally, he put forward the outcome that a good number of treatable patients will be palliated, as most of them should have been treated electively.


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