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IMPROVE: Endovascular strategy for ruptured AAA bests open repair at 3 years
In patients with suspected ruptured abdominal aortic aneurysm, endovascular repair was associated with improved survival, a greater gain in quality-adjusted life-years and reduced costs when compared with conventional open surgery at three years, according to data from the randomized, controlled IMPROVE trial.
From 2009 to 2016, researchers randomly assigned 613 patients with ruptured AAA at 30 vascular centers in the United Kingdom and Canada to undergo endovascular repair, if morphologically feasible, or open repair. Of all patients, 502 underwent emergency repair for rupture. Mean follow-up for mortality was 4.9 years.
During a mid-term period of 3 months to 3 years after the procedure, mortality was lower in the endovascular-repair group vs. the open-repair group (HR = 0.57; 95% CI, 0.36-0.9). By 3 years, fewer patients had died after endovascular repair vs. open repair (48% vs. 56%; OR = 0.73; 95% CI, 0.53-1), according to the data.
Results of a sensitivity analysis of the 502 patients with repaired ruptures were comparable to those from the full cohort, with significantly lower 3-year mortality in the endovascular-repair group vs. the open-repair group (42% vs. 54%; OR = 0.62; 95% CI, 0.43-0.88). After 7 years, however, results indicated no difference between treatment groups (HR = 0.86; 95% CI, 0.68-1.08).
Although average quality of life was similar between treatment groups at 3 years, it was higher among patients who underwent endovascular repair during the first year. This early improvement in quality of life and lower 3-year mortality in the endovascular-repair group translated to an average gain of 0.166 quality-adjusted life-years (QALYs) at 3 years, according to the researchers.
Additionally, patients who underwent endovascular repair compared with open repair had shorter hospital stays (14.4 vs. 20.5 days), leading to reduced costs. The probability of endovascular repair’s cost effectiveness was greater than 90% at all levels of willingness-to-pay thresholds for a QALY gain.
By 3 years, reintervention rates were similar between the endovascular-repair and open-repair groups (HR = 1.02; 95% CI, 0.79-1.32), with both groups seeing slower reintervention rates during the mid-term period.
“This mid-term follow-up provides convincing support for the benefits of an endovascular strategy (EVAR if morphologically feasible) vs. open repair to treat patients with ruptured abdominal aortic aneurysm,” the researchers wrote. “At 3 years, the endovascular strategy offers an increase in QALYs, without an excess of reinterventions, and is cost effective.” – by Melissa Foster
Disclosure: The authors report no relevant financial disclosures.