Outcomes and Costs of Abdominal Aortic Aneurysm Reconstructive Therapy without the Possibility of Emergency Endovascular Treatment: a Double-center Observational Study

Hadadi, László; Druică, Elena; Nicolae, Viorel Constantin; Călburean, Paul-Adrian; Bănceu, Cosmin Marian; Elkahlout, Ayman; Lorenzovici, László; Precup, Andreea Mihaela; Moț, Ștefan; Molnar, Adrian

doi:10.2478/jce-2025-0007

Abstract

Introduction

Abdominal aortic aneurysm (AAA)-associated mortality has remained high in Romania over the past decade. The aim of this study was to evaluate whether the recent introduction of endovascular aneurysm repair (EVAR) has contributed to a decrease in AAA-related mortality in northwestern and central Romania and to identify the main determinants of procedure-related costs.

Methods

We conducted a double-center observational study comparing outcomes and costs in a prospective EVAR arm and a retrospective open surgical reconstruction (OSR) arm.

Results

A total of 117 patients were included (48.7% treated with EVAR; 39.3% presented with ruptured AAAs). OSR was associated with significantly higher post-intervention morbidity (greater number of complications, p < 0.01; longer intensive care unit stay, p < 0.001) and higher in-hospital mortality (p = 0.03). Overall mortality was similar to that reported in Romania before the widespread adoption of EVAR (25.6% vs. 20.3%, p = 0.36). EVAR-related average costs were significantly higher than those associated with OSR, at €13,734 (range: €10,016–€40,363) vs. €5,989 (range: €690–€68,205) (p < 0.001).

Conclusions

The selective introduction of EVAR for elective cases was not associated with a decrease in AAA-related mortality. EVAR remains more expensive than OSR in Romania. These findings suggest that reorganizing AAA management, particularly in emergency settings, might be an important objective in the northwestern and central regions of Romania.

References

Golledge J. Abdominal aortic aneurysm: update on pathogenesis and medical treatments. Nat Rev Cardiol. 2019 Apr;16(4):225–242. doi: 10.1038/s41569-018-0114-9
Open DOI Search in Google Scholar Back to article
Wanhainen A, Verzini F, Van Herzeele I, et al. Editor's Choice - European Society for Vascular Surgery (ESVS) 2019 Clinical Practice Guidelines on the Management of Ab-dominal Aorto-iliac Artery Aneurysms. European Journal of Vascular and Endovascular Surgery. 2019 Jan;57(1):8–93. doi: 10.1016/j.ejvs.2020.09.004
Open DOI Search in Google Scholar Back to article
Chaikof EL, Dalman RL, Eskandari MK, et al. The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm. Journal of Vascular Surgery. 2018 Jan;67(1):2–77.e2. doi: 10.1016/j.jvs.2017.10.044
Open DOI Search in Google Scholar Back to article
van Beek SC, Conijn AP, Koelemay MJ, Balm R. Editor's Choice - Endovascular An-eurysm Repair Versus Open Repair for Patients with a Ruptured Abdominal Aortic Aneurysm: A Systematic Review and Meta-analysis of Short-term Survival. European Journal of Vascular and Endovascular Surgery. 2014 Jun;47(6):593–602. doi: 10.1016/j.ejvs.2014.03.003
Open DOI Search in Google Scholar Back to article
Kontopodis N, Antoniou SA, Georgakarakos E, Ioannou CV. Endovascular vs Open Aneurysm Repair in the Young: Systematic Review and Meta-analysis. J Endovasc Ther. 2015 Dec;22(6):897–904. doi: 10.1177/1526602815606937
Open DOI Search in Google Scholar Back to article
Greenhalgh R. Comparison of endovascular aneurysm repair with open repair in patients with abdominal aortic aneurysm (EVAR trial 1), 30-day operative mortality results: randomised controlled trial. The Lancet. 2004 Sep;364(9437):843–848. doi: 10.1016/S0140-6736(04)16979-1
Open DOI Search in Google Scholar Back to article
Prinssen M, Verhoeven ELG, Buth J, et al. A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms. N Engl J Med. 2004 Oct 14;351(16):1607–1618. doi: 10.1056/NEJMoa042002
Open DOI Search in Google Scholar Back to article
Hinchliffe RJ, Bruijstens L, MacSweeney STR, Braithwaite BD. A Randomised Trial of Endovascular and Open Surgery for Ruptured Abdominal Aortic Aneurysm - Results of a Pilot Study and Lessons Learned for Future Studies. European Journal of Vascular and Endovascular Surgery. 2006 Nov;32(5):506–513. doi: 10.1016/j.ejvs.2006.05.016
Open DOI Search in Google Scholar Back to article
Reimerink JJ, Hoornweg LL, Vahl AC, et al. Endovascular repair versus open repair of ruptured abdominal aortic aneurysms: a multicenter randomized controlled trial. Ann Surg. 2013 Aug;258(2):248–256. doi: 10.1097/SLA.0b013e31828d4b76
Open DOI Search in Google Scholar Back to article
Sidloff D, Stather P, Dattani N, et al. Aneurysm Global Epidemiology Study: Public Health Measures Can Further Reduce Abdominal Aortic Aneurysm Mortality. Circulation. 2014 Feb 18;129(7):747–753. doi: 10.1161/CIRCULATIONAHA.113.005457
Open DOI Search in Google Scholar Back to article
Png CYM, Wu J, Tang TY, Png IPL, Sheng TJ, Choke E. Editor's Choice - Decrease in Mortality from Abdominal Aortic Aneurysms (2001 to 2015): Is it Decreasing Even Faster? European Journal of Vascular and Endovascular Surgery. 2021 Jun;61(6):900–907. doi: 10.1016/j.ejvs.2021.02.013
Open DOI Search in Google Scholar Back to article
Wang Z, You Y, Yin Z, et al. Burden of Aortic Aneurysm and Its Attributable Risk Factors from 1990 to 2019: An Analysis of the Global Burden of Disease Study 2019. Front Cardiovasc Med. 2022 May 31;9:901225. doi: 10.3389/fcvm.2022.901225
Open DOI Search in Google Scholar Back to article
Romanian Ministry of Health. ORDIN nr. 1.117 din 12 august 2010 privind aprobarea Listei materialelor sanitare de care beneficiază bolnavii incluşi în programele naţionale de sănătate de evaluare, profilactice şi cu scop curativ, finanţate din bugetul Fondului naţional unic de asigurări sociale de sănătate în anul 2010. Monitorul Oficial al României. 2010 Aug 31;(614).
Search in Google Scholar Back to article
Molnar A, Săcui D, Scridon T. Risk factors influencing the surgical outcome in 138 consecutive patients with infrarenal aortic aneurysm: experience at the Cluj-Napoca Cardiovascular Surgery Center. Chirurgia (Bucur). 2014 Apr;109(2):223–228.
Search in Google Scholar Back to article
Proiect AngioNet. Available online: https://cluster.angionet.ro/en/category/in-progress-projects/ (accessed on 04 September 2022). [Internet]. [cited 2022 Sep 4]. Available from: https://cluster.angionet.ro/en/category/in-progress-projects/
Search in Google Scholar Back to article
Moll FL, Powell JT, Fraedrich G, et al. Management of Abdominal Aortic Aneurysms Clinical Practice Guidelines of the European Society for Vascular Surgery. European Journal of Vascular and Endovascular Surgery. 2011 Jan;41:S1–S58. doi: 10.1016/j.ejvs.2010.09.011
Open DOI Search in Google Scholar Back to article
Mutschler M, Paffrath T, Wölfl C, et al. The ATLS^® classification of hypovolaemic shock: A well established teaching tool on the edge? Injury. 2014 Oct;45:S35–S38. doi: 10.1016/j.injury.2014.08.015
Open DOI Search in Google Scholar Back to article
Lorenzovici L, Székely A, Nyulas B, Bradács A, Daina L. Controlling in Romanian Hospitals: revenues, costs and contribution after salary increase. IME. 2020;19(1):17–22.
Search in Google Scholar Back to article
Tilea I, Hadadi L, Serban RC, Tilea B. Hybrid repair of a very late, post-aortic coarcta-tion surgery thoracic aneurysm: a case report. J Med Case Rep. 2012 Aug 30;6:255. doi: 10.1186/1752-1947-6-255
Open DOI Search in Google Scholar Back to article
Balanescu SM, Linte AL, Dregoesc IM, Marc MC, Iancu AC. Endovascular treatment of an aortic aneurysm and patent ductus arteriosus. Anatol J Cardiol. 2018 Aug;20(2):130–131. doi: 10.14744/AnatolJCardiol.2018.67365
Open DOI Search in Google Scholar Back to article
Stiru O, Geana RC, Pavel P, et al. Descending Thoracic Aortic Aneurysm Rupture Treated with Thoracic Endovascular Aortic Repair in a Patient with Peripheral Artery Disease. Heart Surg Forum. 2018 Mar 20;21(2):E112–E116. doi: 10.1532/hsf.1895
Open DOI Search in Google Scholar Back to article
Droc I, Raithel D, Calinescu FB. Endovascular treatment of abdominal aortic aneurysms: indications and results. Minim Invasive Ther Allied Technol. 2011 Apr;20(2):117–124. doi: 10.3109/13645706.2011.554842
Open DOI Search in Google Scholar Back to article
Droc I, Calinescu FB, Droc G, Blaj C, Dammrau R. Aortic stenting. Minim Invasive Ther Allied Technol. 2015;24(5):296–304.
Search in Google Scholar Back to article
Ali MM, Flahive J, Schanzer A, Simons JP, Aiello FA, Doucet DR, et al. In patients stratified by preoperative risk, endovascular repair of ruptured abdominal aortic aneu-rysms has a lower in-hospital mortality and morbidity than open repair. J Vasc Surg. 2015 Jun;61(6):1399–1407. doi: 10.1016/j.jvs.2015.01.042
Open DOI Search in Google Scholar Back to article
Dakour-Aridi H, Nejim B, Locham S, Alshwaily W, Malas MB. Anemia and postoperative outcomes after open and endovascular repair of intact abdominal aortic aneurysms. J Vasc Surg. 2019 Mar;69(3):738–751.e2. doi: 10.1016/j.jvs.2018.05.233
Open DOI Search in Google Scholar Back to article
Overbey DM, Glebova NO, Chapman BC, Hosokawa PW, Eun JC, Nehler MR. Morbidity of endovascular abdominal aortic aneurysm repair is directly related to diameter. J Vasc Surg. 2017 Oct;66(4):1037–1047.e7. doi: 10.1016/j.jvs.2017.01.058
Open DOI Search in Google Scholar Back to article
Diehm N, Benenati JF, Becker GJ, et al. Anemia is associated with abdominal aortic aneurysm (AAA) size and decreased long-term survival after endovascular AAA repair. Journal of Vascular Surgery. 2007 Oct;46(4):676–681. doi: 10.1016/j.jvs.2007.06.027
Open DOI Search in Google Scholar Back to article
IMPROVE Trial Investigators, Powell JT, Sweeting MJ, et al. Endovascular or open re-pair strategy for ruptured abdominal aortic aneurysm: 30 day outcomes from IMPROVE randomised trial. BMJ. 2014 Jan 13;348:f7661. doi: 10.1136/bmj.f7661
Open DOI Search in Google Scholar Back to article
Lederle FA, Freischlag JA, Kyriakides TC, et al. Long-Term Comparison of Endovas-cular and Open Repair of Abdominal Aortic Aneurysm. N Engl J Med. 2012 Nov 22;367(21):1988–1997. doi: 10.1056/NEJMoa1207481
Open DOI Search in Google Scholar Back to article
Karthikesalingam A, Holt PJ, Vidal-Diez A, et al. Mortality from ruptured abdominal aortic aneurysms: clinical lessons from a comparison of outcomes in England and the USA. Lancet. 2014 Mar 15;383(9921):963–969. doi: 10.1016/S0140-6736(14)60109-4
Open DOI Search in Google Scholar Back to article
Trenner M, Haller B, Söllner H, et al. 12 Jahre “Qualitätssicherung BAA” der DGG: Teil 2: Trends in Therapie und Outcome des rupturierten abdominellen Aortenaneurysmas in Deutschland zwischen 1999 und 2010. Gefässchirurgie. 2013 Sep;18(5):372–380. doi: 10.1007/s00772-013-1194-9
Open DOI Search in Google Scholar Back to article
Greco G, Egorova N, Anderson PL, et al. Outcomes of endovascular treatment of rup-tured abdominal aortic aneurysms. J Vasc Surg. 2006 Mar;43(3):453–459. doi: 10.1016/j.jvs.2005.11.024
Open DOI Search in Google Scholar Back to article
Mani K, Björck M, Lundkvist J, Wanhainen A. Improved Long-Term Survival After Abdominal Aortic Aneurysm Repair. Circulation. 2009 Jul 21;120(3):201–211. doi: 10.1161/CIRCULATIONAHA.108.832774
Open DOI Search in Google Scholar Back to article
Ockert S, Schumacher H, Böckler D, Megges I, Allenberg JR. Early and midterm results after open and endovascular repair of ruptured abdominal aortic aneurysms in a comparative analysis. J Endovasc Ther. 2007 Jun;14(3):324–332. doi: 10.1583/06-2065.1
Open DOI Search in Google Scholar Back to article
Robinson WP, Schanzer A, Aiello FA, et al. Endovascular repair of ruptured abdominal aortic aneurysms does not reduce later mortality compared with open repair. J Vasc Surg. 2016 Mar;63(3):617–624. doi: 10.1016/j.jvs.2015.09.057
Open DOI Search in Google Scholar Back to article
van Beek SC, Vahl A, Wisselink W, et al. Midterm Reinterventions and Survival After Endovascular Versus Open Repair for Ruptured Abdominal Aortic Aneurysm. Eur J Vasc Endovasc Surg. 2015 Jun;49(6):661–668. doi: 10.1016/j.ejvs.2015.02.015
Open DOI Search in Google Scholar Back to article
Jeon-Slaughter H, Krishnamoorthi H, Timaran D, et al. Effects of Abdominal Aortic Aneurysm Size on Mid- and Long-term Mortality After Endovascular Aneurysm Repair. J Endovasc Ther. 2019 Apr;26(2):231–237. doi: 10.1177/1526602819829901
Open DOI Search in Google Scholar Back to article
Patel VI, Lancaster RT, Ergul E, et al. Postoperative renal dysfunction independently predicts late mortality in patients undergoing aortic reconstruction. J Vasc Surg. 2015 Dec;62(6):1405–1412. doi: 10.1016/j.jvs.2015.07.084
Open DOI Search in Google Scholar Back to article
Beck AW, Goodney PP, Nolan BW, et al. Predicting 1-year mortality after elective ab-dominal aortic aneurysm repair. J Vasc Surg. 2009 Apr;49(4):838–843; discussion 843–844. doi: 10.1016/j.jvs.2008.10.067
Open DOI Search in Google Scholar Back to article
Stather PW, Sidloff D, Dattani N, Choke E, Bown MJ, Sayers RD. Systematic review and meta-analysis of the early and late outcomes of open and endovascular repair of abdominal aortic aneurysm. British Journal of Surgery. 2013 May 3;100(7):863–872. doi: 10.1002/bjs.9101
Open DOI Search in Google Scholar Back to article
Schermerhorn ML, Bensley RP, Giles KA, et al. Changes in Abdominal Aortic Aneu-rysm Rupture and Short-Term Mortality, 1995–2008: A Retrospective Observational Study. Annals of Surgery. 2012 Oct;256(4):651–658. doi: 10.1097/SLA.0b013e31826b4f91
Open DOI Search in Google Scholar Back to article
Mureebe L, Egorova N, Giacovelli JK, Gelijns A, Kent KC, McKinsey JF. National trends in the repair of ruptured abdominal aortic aneurysms. J Vasc Surg. 2008 Nov;48(5):1101–1107. doi: 10.1016/j.jvs.2008.06.031
Open DOI Search in Google Scholar Back to article
Lesperance K, Andersen C, Singh N, Starnes B, Martin MJ. Expanding use of emer-gency endovascular repair for ruptured abdominal aortic aneurysms: disparities in out-comes from a nationwide perspective. J Vasc Surg. 2008 Jun;47(6):1165–1170; discussion 1170–1171. doi: 10.1016/j.jvs.2008.01.055
Open DOI Search in Google Scholar Back to article
Desgranges P, Kobeiter H, Katsahian S, et al. Editor's Choice - ECAR (Endovasculaire ou Chirurgie dans les Anévrysmes aorto-iliaques Rompus): A French Randomized Con-trolled Trial of Endovascular Versus Open Surgical Repair of Ruptured Aorto-iliac An-eurysms. European Journal of Vascular and Endovascular Surgery. 2015 Sep;50(3):303–310. doi: 10.1016/j.ejvs.2015.03.028
Open DOI Search in Google Scholar Back to article
Mohan PP, Hamblin MH. Comparison of endovascular and open repair of ruptured ab-dominal aortic aneurysm in the United States in the past decade. Cardiovasc Intervent Radiol. 2014 Apr;37(2):337–342. doi: 10.1007/s00270-013-0665-4
Open DOI Search in Google Scholar Back to article
Karthikesalingam A, Wanhainen A, Holt PJ, et al. Comparison of long-term mortality after ruptured abdominal aortic aneurysm in England and Sweden. Br J Surg. 2016 Feb;103(3):199–206. doi: 10.1002/bjs.10049
Open DOI Search in Google Scholar Back to article
Călburean PA, Grebenișan P, Nistor IA, et al. Addition of eptifibatide and manual thrombus aspiration to ticagrelor does not improve long-term survival after STEMI treated with primary PCI. Frontiers in Pharmacology. 2024;15:1415025. doi: 10.3389/fphar.2024.1415025
Open DOI Search in Google Scholar Back to article
CASA NAȚIONALĂ DE ASIGURĂRI DE SĂNĂTATE. ORDIN nr. 268 din 23 mai 2013 privind aprobarea Listei materialelor sanitare de care beneficiază bolnavii incluși în programele naționale de sănătate curative, finanțate din bugetul Fondului național unic de asigurări sociale de sănătate. Monitorul Oficial al României. 2013 Jun 5;(326).
Search in Google Scholar Back to article
Bulder RMA, Eefting D, Vriens PWHE, et al. Editor's Choice - A Systemic Evaluation of the Costs of Elective EVAR and Open Abdominal Aortic Aneurysm Repair Implies Cost Equivalence. European Journal of Vascular and Endovascular Surgery. 2020 Nov;60(5):655–662. doi: 10.1016/j.ejvs.2020.07.012
Open DOI Search in Google Scholar Back to article