Recommendation for NHSScotland

Complex endovascular aneurysm repair (C-EVAR) is associated with a limited and low-quality evidence base.

The advantages of C-EVAR remain unclear compared with:
- open surgical repair (OSR), in people for whom OSR is a suitable intervention, and
- non-surgical management, in people for whom OSR is not a suitable intervention.

C-EVAR of complex abdominal aortic aneurysms (AAAs) or thoracoabdominal aneurysms (TAAAs) offers an alternative to OSR and is often considered for patients with perceived moderate/high operative risk.

All patients for whom the use of C-EVAR is being considered should have their case discussed as part of a multidisciplinary team. The consequences of C-EVAR, including uncertainties around reintervention and survival, should be discussed with each patient as part of making a treatment decision.

Within the literature, patient selection between C-EVAR and OSR varies because of a lack of consensus regarding grading of operative risk. NHSScotland should develop a service configuration model that supports a consistent and evidence-based approach to patient assessment and treatment. This will support standardisation of best outcomes for patients and facilitate the collection of outcomes data.

All C-EVAR undertaken should be documented as part of a formal audit and data collection. programme.

NHSScotland is required to consider Scottish Health Technologies Group (SHTG) advice. 

What were we asked to look at

In May 2018, the SHTG published advice on the clinical effectiveness, safety and cost effectiveness of C-EVAR techniques compared with OSR or non-surgical management in patients with a juxtarenal aortic aneurysm (JRAA) or thoracoabdominal aortic aneurysm (TAAA).
The National Services Division (NSD) within NHS National Services Scotland requested that the evidence review and advice is updated to inform their commissioning of future service models.

Why is this important 

The ​Scottish National Thoraco-Abdominal Aortic Aneurysm and Complex Aortic Service is based in the Royal Infirmary of Edinburgh, NHS Lothian. The service provides care for patients in Scotland requiring assessment and treatment for disease of the aortic arch, thoracic, thoracoabdominal or suprarenal abdominal aorta and other complex aortic conditions. This is a specialist service that is funded and managed by NSD.

NSD has advised that since the publication of SHTG’s Advice in 2018, there has been a significant change in clinical practice resulting in greater use of C-EVAR techniques. C-EVAR is available in five boards in NHSScotland, with the centre in NHS Lothian carrying out the most complicated cases.

The increased use of C-EVAR has resulted in increased costs mainly driven by the consumable and device costs.  It is important to ensure the service is providing value for money.

NSD has asked that SHTG advice is updated so that they can reach an informed decision on future service models and whether the service fits within a national designation. SHTG advice will shape the new service level agreement and requests to Board Chief Executives and Scottish Government for funding.

Referred by  

National Services Division within NHS Specialist Services & National Planning, NHS Scotland.