Endovascular repair (EVR) is a less-invasive method for the treatment of abdominal
aortic aneurysms (AAAs) as compared with open surgical repair (OSR). The potential
benefits of EVR include increased patient acceptance, less resource utilization, and
cost savings. This study was designed to determine whether the EVR of AAAs is a cost-effective
alternative to OSR.
A cost-effectiveness analysis was performed using a Markov decision analysis model
to compute long-term survival rates in quality-adjusted life years and lifetime costs
for a hypothetical cohort of patients who underwent either OSR or EVR. Probability
estimates of the different outcomes of the two alternative strategies were made on
the basis of a review of the literature. The average costs of (1) the immediate hospitalization
($16,016 for OSR, $20,083 for EVR), (2) the complications that resulted from each
procedure, (3) the subsequent interventions, and (4) the surveillance protocol were
determined on the basis of average resource utilization as reported in the literature
and from our hospital's cost accounting system. Our measure of outcome was the cost-effectiveness
ratio.
For our base-case analysis (70-year-old men with 5-cm AAAs), EVR was cost-effective
with a cost-effectiveness ratio of $22,826-society usually is willing to pay for interventions
with cost-effectiveness ratios of less than $60,000 (eg, cost-effectiveness ratios
for coronary artery bypass grafting and dialysis are $9500 and $54,400, respectively).
This conclusion did not vary significantly with increases in procedural costs for
EVR (ie, if the cost of the endograft increased from $8000 to $12,000, EVR remained
cost-effective with a cost-effectiveness ratio of $32,881). The cost-effectiveness
of EVR was critically dependent on EVR producing a large reduction in the combined
mortality and long-term morbidity rate (stroke, dialysis-dependent renal failure,
major amputation, myocardial infarction) as compared with OSR (ie, a reduction in
the combined mortality and long-term morbidity rate of OSR from 9.1% to 4.7% made
EVR no longer cost-effective).
Despite the high cost of new technology and the need for close postoperative surveillance,
EVR is a cost-effective alternative for the repair of AAAs. However, the cost-effectiveness
of this new technology is critically dependent on its potential to reduce morbidity
and mortality rates as compared with OSR. EVR may not be cost-effective in medical
centers where OSR can be performed with low risk.