Long-term costs to Medicare associated with endovascular and open repairs of infrarenal and complex abdominal aortic aneurysms

Objective: The vast majority of patients with abdominal aortic aneurysms (AAAs) undergoing repairs receive endovascular interventions (EVARs) instead of open operations (OARs). Although EVARs have better short-term outcomes, OARs have improved longer -term durability and require less radiographic follow-up and monitoring, which may have signi fi- cant implications on health care economics surrounding provision of AAA care nationally. Herein, we compared costs associated with EVAR and OAR of both infrarenal and complex AAAs. Methods: We examined patients undergoing index elective EVARs or OARs of infrarenal and complex AAAs in the 20142019 Vascular Quality Initiative -Vascular Implant Surveillance and Interventional Outcomes Network (VQI-VISION) dataset. We de fi ned overall costs as the aggregated longitudinal costs associated with: (1) the index surgery; (2) reinterventions; and (3) imaging tests. We evaluated overall costs up to 5 years after infrarenal AAA repair and 3 years for complex AAA repair. Multivariable regressions adjusted for case -mix when evaluating cost differences between EVARs vs OARs. Results: We identi fi ed 23,746 infrarenal AAA repairs (8.7% OAR, 91% EVAR) and 2279 complex AAA repairs (69% OAR, 31% EVAR). In both cohorts, patients undergoing EVARs were more likely to be older and have more comorbidities. The cost for the index procedure for EVARs relative to OARs was lower for infrarenal AAAs ($32,440 vs $37,488; P < .01) but higher among complex AAAs ($48,870 vs $44,530; P < .01). EVARs had higher annual imaging and reintervention costs during each of the 5 postoperative years for infrarenal aneurysms and the 3 postoperative years for complex aneurysms. Among patients undergoing infrarenal AAA repairs who survived 5 years, the total 5 -year cost of EVARs was similar to that of OARs ($35,858 vs $34,212; -$223 [95% con fi dence interval (CI), -$3042 to $2596]). For complex AAA repairs, the total cost at 3 years of EVARs was greater than OARs ($64,492 vs $42,212; + $9860 [95% CI, $5835-$13,885]). For patients receiving EVARs for complex aneurysms, physician -modi fi ed endovascular grafts had higher index procedure costs ($55,835 vs $47,064; P < .01) although similar total costs on adjusted analyses ( + $1856 [95% CI, -$7997 to $11,710]; P = . 70) relative to Zenith fenestrated endovascular grafts among those that were alive at 3 years. Conclusions: Longer -term costs associated with EVARs are lower for infrarenal AAAs but higher for complex AAAs relative to OARs, driven by reintervention and imaging costs. Further analyses to characterize the fi nancial viability of EVARs for both infrarenal and complex AAAs should evaluate hospital margins and anticipated changes in costs of devices.