Recommendation for NHSScotland

Complex endovascular repair (EVAR) of juxta-renal aneurysms or thoraco-abdominal aneurysms offers an alternative to open surgical repair (OSR) and is used particularly for patients with perceived moderate/high operative risk. This is a novel treatment associated with limited and low quality evidence. Based on the published literature alone, it is difficult to establish its advantage over OSR in terms of post-operative mortality and complication rates, or to assess its cost-effectiveness.

Within the literature, patient selection between complex EVAR and OSR appears to be variable owing to a lack of consensus regarding grading of operative risk. NHS Scotland should develop a service configuration model that supports a consistent approach and optimises outcomes for patients being assessed and undergoing this intervention. A National Services Scotland (NSS) review of the national thoraco-abdominal aortic aneurysm (TAAA) service is currently underway, and will address issues regarding service provision.

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

What were we asked to look at?

We were asked to provide advice on the clinical and cost-effectiveness of complex endovascular aneurysm repair in patients with juxta-renal or thoraco-abdominal aortic aneurysm compared with open surgical repair, based on the published evidence.  We were also asked to identify the groups of patients that would benefit most, to help inform future NHSScotland service planning.

Why is this important?

Complex endovascular aneurysm repair techniques are high cost procedures and there was perceived to be uncertainty in their clinical and cost-effectiveness. There is variation in the use of these procedures between NHS boards and it is not clear which model of delivery would be most appropriate. 

Referred by

Edinburgh Vascular Service, Royal Infirmary of Edinburgh