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The National Institute for Health and Clinical Excellence (NICE) guidance on the use of endovascular stent-grafts (EVAR) for the treatment of abdominal aortic aneurysms was published in February 2009.1 This technology appraisal guidance should be read in conjunction with the NICE interventional procedure guidance on stent-graft placement in abdominal aortic aneurysm (interventional procedure guidance 163).2 EVAR is recommended as a treatment option for patients with unruptured infra-renal abdominal aortic aneurysms, for whom surgical intervention (open surgical repair or endovascular aneurysm repair) is considered appropriate.
The decision on whether EVAR is preferred to open surgical repair should be made jointly by the patient and his/her clinician after assessment of a number of factors including:
aneurysm size and morphology
patient age, general life expectancy and fitness for open surgery
the short-term and long-term benefits and risks of the procedures including aneurysm-related mortality and operative mortality.
EVAR should only be performed in specialist centres by clinical teams experienced in the management of abdominal aortic aneurysms and with appropriate expertise in all aspects of patient assessment and the use of endovascular aortic stent-grafts.
Endovascular aortic stent-grafts are not recommended for patients with ruptured aneurysms except in the context of research.
Development of the guidance
The appraisal committee first considered the evidence on the clinical effectiveness of EVAR for the treatment of unruptured infra-renal abdominal aortic aneurysms. Four randomised controlled trials (RCTs) were identified3 4 5 6 7 8 comparing EVAR with open surgical repair (OSR) and three registries,9 10 11 12 13 14 which indicated that EVAR had benefits in terms of reduced rates of operative and aneurysm-related mortality in the medium term. However, these findings were not accompanied by a reduction in all-cause mortality and were associated with increased rates of complications and re-interventions for EVAR compared with OSR.
Evidence from clinical specialists …