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The use of fenestrated and branched endovascular aneurysm repair for juxtarenal and thoracoabdominal aneurysms: a systematic review and cost-effectiveness analysis.

Armstrong, N; Burgers, L; Deshpande, S; Al, M; Riemsma, R; Vallabhaneni, SR; Holt, P; Severens, J; Kleijnen, J (2014) The use of fenestrated and branched endovascular aneurysm repair for juxtarenal and thoracoabdominal aneurysms: a systematic review and cost-effectiveness analysis. Health Technol Assess, 18 (70). pp. 1-66. ISSN 2046-4924 https://doi.org/10.3310/hta18700
SGUL Authors: Holt, Peter James Edward

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Abstract

BACKGROUND: Patients with large abdominal aortic aneurysms (AAAs) are usually offered reparative treatment given the high mortality risk. There is uncertainty about how to treat juxtarenal AAAs (JRAAAs) or thoracoabdominal aortic aneurysms (TAAAs). Endovascular repair of an abdominal aortic aneurysm (EVAR) is often seen as safer and easier than open surgical repair (OSR). However, endovascular treatment of JRAAAs or TAAAs requires specially manufactured stent grafts, with openings to allow blood to reach branches of the aorta. Commissioners are receiving increasing requests for fenestrated EVAR (fEVAR) and branched EVAR (bEVAR), but it is unclear whether or not the extra cost of fEVAR or bEVAR is justified by advantages for patients. OBJECTIVE(S): To assess the clinical effectiveness, safety and cost-effectiveness of fEVAR and bEVAR in comparison with conventional treatment (i.e. no surgery) or OSR for two populations: JRAAAs and TAAAs. DATA SOURCES: Resources were searched from inception to October 2013, including MEDLINE (OvidSP), EMBASE (OvidSP) and the Cochrane Central Register of Controlled Trials (Wiley) and, additionally, for cost-effectiveness, NHS Economic Evaluation Database (NHS EED; Wiley) and EconLit (EBSCOhost). Conference abstracts were also searched. REVIEW METHODS: Studies were included based on an intervention of either fEVAR or bEVAR and a comparator of either OSR or no surgery. For clinical effectiveness, observational studies were excluded only if they were not comparative, i.e. explicitly selected on the basis of prognosis. RESULTS: For clinical effectiveness, searches retrieved 5253 records before deduplication. Owing to overlap between the databases, 1985 duplicate records were removed. Of the remaining 3268 records, based on titles and abstracts, 3244 records were excluded, leaving 24 publications to be ordered. All 24 studies were excluded as none of them satisfied the inclusion criteria. Sixteen studies were excluded on study design, six on intervention and two on comparator. Five out of 16 studies excluded on study design reported a comparison. However, all of the studies acknowledged that they had groups that were not comparable at baseline given that they had selectively assigned younger, fitter patients to OSR. Therefore, these studies were considered 'non-comparative'. For cost-effectiveness, searches identified 104 references before deduplication. Owing to overlap between the databases, 34 duplicate records were removed. Of the remaining 70 records, seven were included for the full assessment based on initial screening. After a full-text review, no studies were included. Because of the lack of clinical effectiveness evidence and difficulty in estimating costs given the rapidly changing and variable technology, a cost-effectiveness analysis (CEA) was not performed. Instead a detailed description of modelling methods was provided. CONCLUSIONS: Despite a thorough search, no studies could be found that met the inclusion criteria. All studies that compared either fEVAR or bEVAR with either OSR or no surgery explicitly selected patients based on prognosis, i.e. essentially the populations for each comparator were not the same. Despite not being able to conduct a CEA, we have provided detailed methods for the conduct if data becomes available. FUTURE WORK: We recommend at least one clinical trial to provide an unbiased estimate of effect for fEVAR/bEVAR compared with OSR or no surgery. This trial should also collect data for a CEA. STUDY REGISTRATION: This study is registered as PROSPERO CRD42013006051. FUNDING: The National Institute for Health Research Health Technology Assessment programme.

Item Type: Article
Additional Information: © Queen’s Printer and Controller of HMSO 2014. This work was produced by Armstrong et al. under the terms of a commissioning contract issued by the Secretary of State for Health. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.
Keywords: Adult, Aged, Aortic Aneurysm, Cost-Benefit Analysis, Databases, Factual, Endovascular Procedures, Female, Humans, Male, Middle Aged, Stents, Young Adult, Humans, Aortic Aneurysm, Stents, Databases, Factual, Adult, Aged, Middle Aged, Cost-Benefit Analysis, Female, Male, Young Adult, Endovascular Procedures, Health Policy & Services, 1117 Public Health And Health Services, 0807 Library And Information Studies, 0806 Information Systems
SGUL Research Institute / Research Centre: Academic Structure > Molecular and Clinical Sciences Research Institute (MCS)
Academic Structure > Molecular and Clinical Sciences Research Institute (MCS) > Vascular & Cardiac Surgery (INCCVC)
Journal or Publication Title: Health Technol Assess
ISSN: 2046-4924
Language: eng
Dates:
DateEvent
December 2014Published
June 2014Accepted
Publisher License: Publisher's own licence
Projects:
Project IDFunderFunder ID
NIHR-CS-011-008Department of HealthUNSPECIFIED
PubMed ID: 25522080
Web of Science ID: WOS:000346736900001
Go to PubMed abstract
URI: https://openaccess.sgul.ac.uk/id/eprint/107723
Publisher's version: https://doi.org/10.3310/hta18700

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