Invited commentary

Article Outline

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This report constitutes a best-guess snapshot of costs incurred during the rapid evolution of practice norms for endovascular aneurysm repair (EVAR) placement and follow-up. Averaging costs for postoperative protocol compliance between 1999 and 2006, given multiple device upgrades, steady improvement in computed tomography (CT)-based image quality (20 catheter-based angiograms were performed for endoleak analysis in this study), better understanding of the significance and natural history of type II endoleaks, and better options for secondary intervention (eg, CT-guided glue or thrombin injection) is misleading and likely overestimates the essential underlying cost of contemporary long term EVAR patient management. The first 50 patients in the Ochsner EVAR practice were excluded to minimize the cost impact of the steep initial phase of the procedural learning curve; given their protean manifestations, the endoleak management learning curve, while flatter, is undeniably longer. And, even prospectively acquired data does not lend itself well to standardization during retrospective analysis (eg, “additional studies were left to the discretion of the individual surgeon”). Nearly half of the patients did not complete follow-up as requested. What were the clinical consequences of these missed visits? What would it have cost to have all 136 patients achieve recommended endpoints? Is it possible that less rigorous follow-up for all patients would have provided comparable outcomes at lower cost? Across the country, secondary intervention rates are decreasing despite increasingly aggressive EVAR patient selection. While critically important to the future of surgical abdominal aortic aneurysm management, the challenge inherent in this analysis is the evolutionary nature of EVAR and the applicability of historical cost data to contemporary practice.