Endovascular Aortic Aneurysm and Dissection Repair (EVAR) in Iran: Descriptive Midterm Follow-up Results

Cost-effectiveness of a population-based AAA screening program for men over 65 years old in Iran

BACKGROUND

Screening program tend to recognized patients in their early stage and consequently improve health outcomes. Cost-effectiveness of the abdominal aortic aneurysm (AAA) screening program has been scarcely studied in developing countries. We sought to evaluate the cost-effectiveness of a screening program for the abdominal aortic aneurysm (AAA) in men aged over 65 years in Iran.

METHODS

A Markov cohort model with 11 mutually exclusive health statuses was used to evaluate the cost-effectiveness of a population-based AAA screening program compared with a no-screening strategy. Transitions between the health statuses were simulated by using 3-month cycles. Data for disease transition probabilities and quality of life outcomes were obtained from published literature, and costs were calculated based on the price of medical services in Iran and the examination of the patients' medical records. The outcomes were life-years gained, the quality-adjusted life-year (QALY), costs, and the incremental cost-effectiveness ratio (ICER). The analysis was conducted for a lifetime horizon from the payer's perspective. Costs and effects were discounted at an annual rate of 3%. Uncertainty surrounding the model inputs was tested with deterministic and probabilistic sensitivity analyses.

RESULTS

The mean incremental cost of the AAA screening strategy compared with the no-screening strategy was $140 and the mean incremental QALY gain was 0.025 QALY, resulting in an ICER of $5566 ($14,656 PPP) per QALY gained. At a willingness-to-pay of 1 gross domestic product (GDP) per capita ($5628) per QALY gained, the probability of the cost-effectiveness of AAA screening was about 50%. However, at a willingness-to-pay of twice the GDP per capita per QALY gained, there was about a 95% probability for the AAA screening program to be cost-effective in Iran.

CONCLUSIONS

The results of this study showed that at a willingness-to-pay of 1 GDP per capita per QALY gained, a 1-time AAA screening program for men aged over 65 years could not be cost-effective. Nevertheless, at a willingness-to-pay of twice the GDP per capita per QALY gained, the AAA screening program could be cost-effective in Iran. Further, AAA screening in high-risk groups could be cost-effective at a willingness-to-pay of 1 GDP per capita per QALY gained.

Fenestrated Endovascular Aortic Aneurysm Repair (FEVAR) for Complex Thoracoabdominal and Abdominal Aortic Aneurysms: First Iranian FEVAR Series Report with Mid-Term Follow-Up

Endovascular treatment of aortic diseases has improved in recent years. More complex thoracoabdominal and juxtarenal abdominal aortic aneurysms can now be treated with new stent grafts and techniques. Fenestrated endovascular aortic aneurysm repair (FEVAR) with fenestrated stent grafts was commenced in our center after hundred cases of endovascular aortic repair, and so far 4 serial complex cases deemed inoperable (2 juxtarenal abdominal aortic aneurysms, 1 thoracoabdominal aneurysm, and 1 thoracoabdominal pseudoaneurysm) have been treated with FEVAR. All these patients needed custom-made stent grafts, which were designed and implanted successfully under general anesthesia in the catheterization laboratory. They were followed up for more than 1 year, with a median follow-up period of 23.0 months. There were no major in-hospital or short-term complications. Only 1 patient had midterm unilateral iliac artery thrombosis, which was successfully managed interventionally. Computed tomography angiography at 1 year's follow-up showed that the stent grafts were patent and their visceral branch cover stents had no endoleak.

Transcatheter heart valve in valve implantation with Edwards SAPIEN bioprosthetic valve for different degenerated bioprosthetic valve positions (First Iranian ViV report with mid-term follow up)

Introduction: After early successful experience with transcatheter aortic valve replacement (TAVR), concept of transcatheter implantation of a new valve within a failing bioprosthetic valve emerged. Valve-in-valve (ViV) implantation seems to be a simpler option for high risk surgical patients.

Methods: We performed five ViV procedures in different valve positions. We included patients with failing bioprosthetic valves with high surgical risk due to concomitant comorbidities. We performed 2 transapical ViV procedures for failing mitral bioprosthetic valves, 1 transfemoral procedure for failing pulmonary valve and 2 transfemoral ViV implantation for failing tricuspid bioprosthetic valves.

Results: The procedures were successfully completed in all 5 cases with initial excellent fluoroscopic and echocardiographic verification. There was no valve embolization or paravalvular leakage in any of the cases. Transcatheter valve function was appropriate with echocardiography. Post procedural clinical adverse events like pleural effusion and transient ischemic attack were managed successfully. In midterm follow up all cases remained in appropriate functional class except from the transcatheter pulmonary valve which became moderately stenotic and regurgitant.

Conclusion: As the first Iranian all-comers case series with midterm follow up for ViV implantation, we had no mortality. Interestingly none of our patients had neurologic sequelae after the procedure. Midterm follow up for our patients was acceptable with good functional class and appropriate echocardiographic findings. Due to high surgical risk of the redo procedure after failing of a bioprosthetic valve especially in elderly patients with comorbidities, ViV implantation would be a good alternative to surgery for this high risk group.