Rob Morgan of St George’s NHS Trust, London, UK, took on the redoubtable Kevin Burnand of King’s College London, UK, in a debate at the CX Symposium on Sunday 5 April 2009. Morgan was opposing the motion “A fit 69-year-old with an abdominal aortic aneurysm should have open repair”.
“I’m delighted that Roger [Greenhalgh] has invited me back for my last appearance at Charing Cross before I fade off into the distance,” said Burnand, referring to his impending retirement.
This was always set to be an enjoyable contest, with Morgan describing Burnand as holding “Luddite views” prior to the clash, and Burnand saying: “I am looking forward to debating a clinical subject with a radiologist; a group of doctors not noted for their clinical skills!”
Burnand told delegates that comparisons of open and endovascular repair are already unbalanced: “If you’re going to stent an aneurysm, you have to have favourable anatomy for a start, so it’s not an even playing field. The worst anatomy gets an open operation. He also listed the contraindications for stenting.
Burnand showed photographs of Greenhalgh and Jan Blankensteijn, who lead on the EVAR and DREAM trials, respectively. These trials, he conceded, have shown a significant reduction in early mortality for endovascular repair; this could, he said, prove to be even lower than 2% when the final results are available.
But what about the two- to four-year results, he asked? “The DREAM trial showed no difference in all-cause mortality, and nor did EVAR 1. But both these studies were under powered. The aneurysm mortality was significantly lower, but there was a 40% complication rate after endovascular repair, and a 20% reintervention rate. And those are figures that won’t go away.”
He also reminded delegates of the surprising early results of the DREAM trial, which suggest that there may be an increased long-term mortality rate with endovascular repair. “This may just be a statistical quirk of the way it’s been analysed, or it may be real, related to all those reinterventions that are going to keep Dr Morgan’s future in fine fettle!” he said.
“We’ve heard a huge amount about costs,” he said, referring to the earlier presentation from David Epstein of the University of York, UK. “I didn’t understand a bloody thing at the end of all that lot, because it seems to me like you’re making all sorts of ‘guestimates’.”
“Essentially, what you’re asking is ‘live now, pay later’,” he said, and, perhaps explaining his decision to retire, added, “Sitting and doing loads of endovascular repairs for the rest of my life would like watching paint dry.”
Morgan opened his stand against the motion by echoing an earlier statement by Florian Dick, Inselspital Bern, Switzerland: “An informed patient chooses endovascular repair.”
Morgan said that the patient wants to whether he or she will survive the operation, whether they will develop life-threatening complications, how long until they will be discharged from hospital, and whether they can expect problems when they return home.
“The fit 69-year-old patient is less likely to die after endovascular repair,” he told delegates. “This is a fact, not a controversy. It is established by all data available to us.”
He went further, and claimed that all major complications are reduced with endovascular repair: “You have less chance of having myocardial infarction, reduced chance of pneumonia, and reduced chance of renal failure.” He also highlighted that discharge into a nursing home was higher with open repair.
“Much has been made of increased complication rates after EVAR,” he said. Overall complication rates of 35% do, he conceded, seem high when compared to 8% for open repair. But he demonstrated that most of these complications are type two endoleaks, without which the complication rate is much lower.
Similarly, he said the reintervention rates paint a misleading picture of endovascular repair, because the majority are minor. For open repair, on the other hand, Morgan says that the reintervention rate is underestimated, and pointed to one study in which it was nearly 10% (Schermerhorn, et al NEJM 2008).
“How fit is a 69yr old? How long can he expect to live?” asked Morgan. A fit 69-year-old male can expect to live to 81 years. “A ‘Fit’ male with an abdominal aortic aneurysm is not that fit at all! He has a life expectancy of around 69 years!”
Delegates voted narrowly against the motion – 54% to 46% – prompting Frans Moll, chairing the session, to say: “This is historical! 2009 and it’s still so close!”