EVAR has replaced the old surgical standard: true? Jan D. Blankensteijn, MD

Transcription

1 EVAR has replaced the old surgical standard: true? Jan D. Blankensteijn, MD MEET, Cannes, 26/6/2008

2 No conflicts of interest Jan D. Blankensteijn, MD

3 When can we safely state that EVAR has replaced the old surgical standard? When at least half of all infrarenal AAA that are potentially suitable for EVAR are actually treated with EVAR EVAR suitability about 50% (30-70%) EVAR has replaced the old surgical standard when > 25% of all AAA gets EVAR 3

4 Has EVAR replaced the old surgical standard? What do randomized trials say? DREAM and EVAR What do surgeons say? Questionnaire What is practice policy? EVEM Panel report 2000 vs

5 Results Randomized Trials All-cause Mortality 30 days 2 years OR EVAR OR EVAR 4.6% 1.2% ±10% ±10% 4.7% 1.7% ±10% ±10% 5

6 Main Trial Results EVAR as compared to Open Repair: Perioperative survival benefit (HR ±3) Perioperative outcomes much better Limited survival benefit, only in 1 st postop year Aneurysm-related mortality benefit 3% at 2 years Limited and short-lived (3M) QoL benefit Not a cost-effective alternative Long-term results are awaited 6

7 Fit patients Glasgow Aneurysm Score J Vasc Surg 2008;47: Customized Prob. Index Br J Surg 2007;94: EVAR-benefit compared to Open Repair is most convincing in patients with best fitness scores EVAR Is Best For Fitter Patients 7

8 Choosing best management of AAA patients Jack L. Cronenwett, MD Editorial to EVAR-trial results. Lancet. 2005;365:

9 Choosing best management of AAA patients High Operative Risk Low Poor Anatomical Suitability for EVAR Excellent 9

10 Before Endovascular Repair High Medical Management Operative Risk Grey Area Open Repair Low 10

11 Parodi s Concept of EVAR High Medical Management EVAR Operative Risk Grey Area Open Repair Low Unsuitable Suitable Anatomical Suitability for EVAR 11

12 Before the Trials High Medical Management Operative Risk Grey Area EVAR Low Open Repair Unsuitable Suitable Anatomical Suitability for EVAR 12

13 Before the Trials effect of trials High Medical Management EVAR-2 effect Operative Risk Grey Area EVAR Low EVAR-1/DREAM effect Open Repair Unsuitable Suitable Anatomical Suitability for EVAR 13

14 Before the Trials effect of trials High Medical Management EVAR Operative Risk Grey Area Low Open Repair Unsuitable Suitable Anatomical Suitability for EVAR 14

15 After the Trials: Louise Brown & Roger Greenhalgh High Medical Management Operative Risk Grey Area Open Repair EVAR Low Unsuitable Suitable Anatomical Suitability for EVAR 15

16 My interpretation High Medical Management Operative Risk Grey Area Open Repair EVAR Low Unsuitable Anatomical Suitability for EVAR Suitable 16

17 Current Situation High Medical Management Operative Risk? EVAR Low Poor Unsuitable Concessions Anatomical Suitability for EVAR Suitable Excellent 17

18 Current Situation High Medical Management Operative Risk EVAR Low Poor Unsuitable Concessions Anatomical Suitability for EVAR Suitable Excellent 18

19 Future Situation High Medical Management Operative Risk EVAR Low Poor Unsuitable Concessions Anatomical Suitability for EVAR Suitable Excellent 19

20 What do surgeons think? Dutch Questionnaire 2006 Vascular surgery in NL: General Surgeons Vascular Surgeons /w VS-certificate (N=±250) Survey among all surgeons (N=±1000) and trainees (N=±400) in the Netherlands Return questionnaire only if taking care of AAA-patients 20

21 Clinical Dilemma Two patients with AAA of Ø 65mm Anatomically and clinically perfectly suitable for both open and endovascular repair: Patient A: 65 y/o, no comorbidity Patient B: 77 y/o, mild comorbidity Which treatment for either patient did you prefer before the publications of the DREAM and EVAR-1 trials, and which do you prefer after? 21

22 Patient A: 65 y/o, no comorbidity % N=138 74% N= % 26% N=54 N=50 0 OR Before EVAR OR After EVAR 22

23 Patient B: 77 y/o, mild comorbidity % 73% N=144 N= % 27% N=48 N=52 OR EVAR OR EVAR Before After 23

24 Any Change of Opinion (Patient A or B) 50% 40% 30% N=12 N=47 20% N=6 10% 0% Resident (N=38) Surgeon (N=25) Vascular Surgeon (N=129) 24

25 Net Change (Patient A or B) - Vascular Surgeons (N=129) - In favor of EVAR: 15/129 = 11,6% (95% CL: 6,1% 17,2%) In favor of OR: 29/129 = 22,5% (95% CL: 15,3% 29,7%) Net Change in favor of OR: 14/129 = 10,9% (95% CL: 5,5% 16,2%), p=

26 What is practice policy? European Vascular and Endovascular Monitor (EVEM)-panel report (BIBA Medical) Q Q

27 Percentage (95% confidence limits) of AAA treated endovascularly Courtesy of EVEM-panel, BIBA Medical 27

28 Percentage (95% confidence limits) of AAA treated endovascularly Courtesy of EVEM-panel, BIBA Medical 28

29 Percentage (95% confidence limits) of AAA treated endovascularly Overall in Europe Courtesy of EVEM-panel, BIBA Medical 29

30 EVAR has replaced the old surgical standard: true? YES! MEET, Cannes, 26/6/2008