Contemporary cost-effectiveness of endovascular versus open surgical repair of for elective infrarenal abdominal aortic aneurysms in the United Kingdom.

Abstract

Background: Endovascular aneurysm repair (EVAR) and open surgical repair (OSR) are both used for elective unruptured infrarenal abdominal aortic aneurysm (AAA), but their relative cost-effectiveness in the UK NHS remains uncertain.

Research design and methods: A lifetime Markov cohort model compared EVAR and OSR, incorporatingwaiting-list and perioperative mortality, postoperative survival, reinterventions, and imaging surveillance. Time-varying mortality effects were derived from reconstructed individual-patient-data meta-analysis, with equal long-term mortality assumed in the base case. Costs and QALYs were discounted at 3.5%. Uncertainty was explored through deterministic, probabilistic (10,000 iterations), and scenario analyses using alternative survival models.

Results: EVAR had higher lifetime costs (£17,710 vs £16,191) but greater QALYs (6.373 vs 6.219), yielding an ICER of £9,865/QALY. Probabilistic analysis produced a mean ICER of £9,793/QALY, with EVAR cost-effective in 56.1% and 62.2% of simulations at £20,000 and £30,000/QALY thresholds, respectively. Results were sensitive to survival modeling assumptions, EVAR device costs, perioperative mortality, and surveillance intensity.

Conclusions: Under contemporary time-varying mortality assumptions, EVAR is likely cost-effective versus OSR at standard UK thresholds, though conclusions depend on long-term survival assumptions and surveillance intensity.