The authors should be congratulated on their study showing acceptable cost-effectiveness of EVAR of AAA in Portugal. The issue is very pertinent considering the economical difficulties Portugal has been facing in recent years.
Several considerations can be done when analyzing the results. The present study reinforces previous observations of the similar costs of EVAR and open surgical repair (OSR) in a comunity setting in other countries.1 However, the results from different countries should be analyzed with care since there are variations in the costs of the hospital resources used and pricing of the grafts that may influence the cost-effectiveness in the different settings. This is one of the reasons behind the high importance of present article – it uses the available data and gives the possible assessment of the Portuguese situation at the moment. Moreover, although early studies had shown high costs of EVAR mostly due to the graft price, recent literature suggests that the initial costs of EVAR may be lower than OSR.2 The costs associated with EVAR follow-up have also been pointed out as a drawback of EVAR. However, there seems to be increasing evidence that simplified follow-up programs can be adopted taking advantage of ultrasound and less frequent examinations,3,4 which will naturally limit the costs as well.5 Another issue that needs to be taken into consideration, as the authors of the present study point out, is the expected future improvement of the cost-effectiveness of EVAR if the long-term results of the technique maintain the initial good figures. To achieve this it is mandatory that only patients with proper anatomies are selected to standard EVAR6 and that open repair or more advanced techniques are used whenever required.7 Finally, there are two other factors likely to contribute to the continued future improvement of the cost-effectiveness of EVAR: the trend of endografts to decrease in price as it usually happens will medical devices and the constant improving results with the new iterations of the devices.
In summary, the work of the authors is of the utmost importance since it shows that EVAR is showing promising cost effectiveness in the Portuguese context. Moreover, this cost effectiveness can be expected to improve further in the future which may reduce the economical restrictions for the application the technology. Further studies, with more robust raw data, possibly gathered through prospective, standardized and nationwide registers, should be done to guarantee the acceptable cost-effectiveness of the treatment modalities chosen.