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Is 5.5 cm Still the Optimal Size Threshold to Treat AAA in Men? A Contemporary Cost-Utility Analysis
David H. Stone1, *Jesse A. Columbo
1, *Anders Wanhainen
3, *Aravind Ponukumati
1, Thomas Huber
2, *Sebastian Debus
4, *Rebecca Scully
1, *Michol Cooper
2, Philip P. Goodney
1, Gilbert R. Upchurch
2, Salvatore T. Scali
21Vascular Surgery, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire; 2Surgery, University of Florida, Gainesvulle, Florida; 3Vascular Surgery, Uppsala University, Uppsala; 4University of Hamburg, Hamburg
Objective(s): The historical 5.5 cm threshold for elective abdominal aortic aneurysm (AAA) repair in men is primarily consensus-based, lacking robust evidence, and its relevance has become increasingly uncertain given recent observed reductions in rupture potential. It is therefore warranted to evaluate whether a 5.5 cm diameter threshold for surgery is cost-effective. The purpose of this analysis was to determine the contemporary cost per quality-adjusted life years (QALY) gained for AAA repair in current practice to best ascertain the optimal size threshold for AAA repair.
Methods: A Markov-chain analysis was used to estimate the cost-utility of endovascular AAA repair (EVAR) and open surgical repair (OSR) versus surveillance. Social Security Administration life tables were used for survival, and Vascular Quality Initiative registry and Medicare data were used for complications, late-rupture, open conversion, and modified survival estimates. QALYs were calculated based on published estimates. Two cost-utility thresholds (willingness to pay) were used, $100,000/QALY (U.S. standard), and $40,000/QALY (30,000 GBP in 2025 U.S. dollars, UK-NICE standard). A range of rupture risks were modeled given the clinical uncertainty of true size-associated AAA rupture risk. The base case was a 70-year-old male in average health with a 10-year time horizon.
Results: At a cost-utility threshold of $100,000/QALY, immediate EVAR was cost-effective if the annual risk of AAA rupture was ≥2.2% (
Figure). Using the same cost-utility threshold, OSR was cost-effective if the annual risk of AAA rupture was ≥3.4%. At a cost-utility threshold of $40,000/QALY, immediate EVAR was cost-effective if the annual risk of AAA rupture was ≥5.0%, and OSR was cost-effective if the annual risk of AAA rupture was ≥6.8%. Assuming an annual rupture risk of 0.4%, (which corresponds to a 5.0-5.5 cm AAA) the cost per added QALY was $1,233,000 for EVAR. At this threshold, OSR resulted in a loss of QALYs. Sensitivity analyses around the risk of complications, utilities associated with complications, and the cost of EVAR and OSR, did not meaningfully change these estimates.
Conclusions: This analysis demonstrates the highly dependent relationship between the cost-effectiveness of AAA repair and the corresponding underlying size associated rupture risk. Given that current estimates for annualized rupture risk for 5.0-5.5 cm AAAs may be as low as 0.4%, the historical threshold for repair of 5.5 cm may not be cost-effective from a population health perspective. Accordingly, it may be appropriate to revisit evidence-based guidelines which more accurately reflect the evolution in diminished AAA rupture potential, and current healthcare costs, to best allocate resources to those most likely to derive benefit.
Figure: Cost-utility of immediate abdominal aortic aneurysm repair versus surveillance for a 70-year-old male in average health, across possible rupture probabilities.
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