On 15 April 2020, the Vascular Society of Great Britain and Ireland (Vascular Society) issued a comment on the recently published UK National Institute of Health and Care Excellence (NICE) guidelines on abdominal aortic aneurysm (AAA) diagnosis and management.
The guidelines, published on 19 March 2020, encouraged discussion between physicians and patients to consider the risks of any intervention versus no intervention and, while the guidelines are in favour of open repair for most patients, they also highlight circumstances in which open repair is contraindicated because of structural or anaesthetic medical comorbidities.
The Vascular Society comment reads:
“NICE has now published the final version of the guidance document on the management of AAA in the UK. The Vascular Society endorses the recommendations and plans to work with NICE to implement them once normal practice resumes after the COVID-19 pandemic.
“NICE has considered the implications of limited patient and clinician choice in the draft proposal and now gives autonomy to the individual doctor-patient relationship. The new document recognises that there may be some clinical situations when EVAR will be the optimum choice for patients under clearly defined circumstances. These now include (in addition to the hostile abdomen) other anatomical and physiological considerations. The final recommendations empower surgeons to guide their patients to make the best decision for them as an individual, having been fully informed of the pros and cons of all treatment options.
“This guidance is now better aligned to recommendations recently published in Europe and the United States. Importantly, these recommendations strike a pragmatic balance between the most durable treatment of open surgery for those fit enough to benefit from it, but at the same time, allows for endovascular intervention (where appropriate) for those not suitable for open surgery. With the current knowledge about the poorer outcomes of EVAR in adverse anatomy, consideration of the quality of the proximal seal zone and device IFU will be important. It is envisaged that the vascular MDT will be the decision-making tool to implement the current guidelines and this will be monitored via the NVR. We are fortunate to be ahead of the game in this respect in vascular surgery.
“For cases outside of standard IFU, younger and fitter patients should be considered for open surgery and we feel there should not be a ‘knee-jerk’ move to custom devices without careful consideration of life expectancy and potential patient benefit. However, custom EVAR is acknowledged as being a vital option in some cases and is now accepted under certain conditions of scrutiny. The VS encourages members to enrol such patients in the UK Compass study in addition to the NVR. Prospective monitoring of the short and long-term outcomes of such devices is vital and we endorse the recommendation by NICE in this respect.
“Vascular surgeons want the best outcome for their patients, and patients want the most durable repair by the least invasive intervention. Whilst accepting there may be a partial return to open surgery in some cases (which has already been witnessed from the NVR), we believe the ability to continue with both standard and custom EVAR is also crucial in furthering research and development into better endovascular devices for the future.”