Surgical Science, 2012, 3, 436-444
http://dx.doi.org/10.4236/ss.2012.39087 Published Online September 2012 (http://www.SciRP.org/journal/ss)
Health Related Quality of Life after Treatment of
Abdominal Aortic Aneurysm with Open and Endovascular
Techniques—A Two-Ye ar Follow Up
Monica Pettersson1,2*, Ingegerd Bergbom2, Erney Mattsson3
1Department of Vascular Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
2Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
3Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
Received June 20, 2012; revised July 25, 2012; accepted August 11, 2012
ABSTRACT
Background: Patients with Abdominal Aortic Aneurysm can be treated with two different surgical methods: Open
Repair (OR) or Endovascular Aortic Repair (EVAR). These two different treatments can probably result in different
sense of Health Related Quality of Life, both in a short term and a long term perspective. The purpose of this prospec-
tive study was to examine patients’ Health Related Quality of Life after surgical treatment of Abdominal Aortic Aneurysm
over two years using different instruments for the observations. Methods: Patients were invited consecutively to answer
questionnaires before operation, and 1, 12 and 24 months after surgery. The study was conducted by using the Health
Related Quality of Life questionnaires Sh ort Form (SF-36) and Nottingham Health Profile (NHP). 76 patient (40 in the
OR and 36 in the EVAR group ) participated in the study. The mean age in the OR group were 68 years, range 52 - 80
and in the EVAR group 75 years, range 65 - 85. The results from these two groups of patients were compared to a
matched reference group. Results: Both patients treated with EVAR and OR rated their Health Related Quality of Life
significantly lower in the domain of Mental Health in relation to a matched reference population before surgery. This
difference was not present two years after interv ention. After one month Health related q ualities of life were worse for
the OR group. After two years significant improvements in relation to baseline were observed only among patients in
the OR group. No such long-term benefits were seen in the EVAR group. Conclusions: As the component Mental
Health seemed to be impaired for these study groups before surgery in relation to the matched reference group, nursing
and doctors care actions may be of importance during the pre-operative phase. In the short perspective Health Related
Quality of Life is worse for OR patients than the EVAR group but in the long term perspective impro v eme n ts b ey on d p re -
operative status can only be seen with OR patients.
Keywords: Advanced Practice; Vascular Surgery; Health Related Quality of Life; Vascular Disease; Abdominal Aortic
Aneurysm
1. Introduction
Patients with Abdominal Aortic Aneurysms (AAA) can
be treated with Open Repair (OR) or Endovascular An-
eurysm Repair (EVAR). OR is the traditional method
with a higher rate of immediate cardiovascular and
pulmonary complications [1,2]. The cumulative survival
rates seem to be similar after two years for OR and
EVAR [2]. EVAR is connected to a life-long follow up
with a potential need for new interventions [3]. One can
expect that these two different treatment modalities
might result in different qualities of life, in a short as
well as a long term perspective. In several studies Health
Related Quality of Life (HRQoL) has been examined for
patients treated for AAA [4-11]. Previous studies show
that patients who have been subjected to OR have more
pain and have a longer hospital stay than those treated
with EVAR [5,7]. In a randomised study it was found
that there was a small, yet significant, HRQoL advantage
for EVAR as compared to OR in the early postoperative
period. At 6 months and later however, patients reported
better QOL after OR than after EVAR [9]. A review arti-
cle have demonstrated that the results after surgery is not
consistent and there are variations between benefits for
OR and EVAR [12]. Using a questionnaire, Malina et al.
(2000) found that about 50% of patients found OR to be
a difficult experience as compared to 15% of patients
treated with EVAR. No studies have simultaneously used
different HRQoL instruments on the same study groups,
*Corresponding a uthor.
C
opyright © 2012 SciRes. SS

M. PETTERSSON ET AL. 437
to support the findings. Furthermore, no long-term studies
are present. The aim of this prospective study was to ex-
amine patients’ HRQoL after open and endovascular re-
pair of AAA over two years using different instruments
for the observations. It is important from a nursing per-
spective to investigate patients recovery process follow-
ing OR and EVA R as such knowledge can be used in the
preparation of patients before surgery.
Theoretical Framework
Quality of life and health is not easy to measure and
Gadamer [13] stated that it is impossible to measure or
quantify it. It can be described as a value related to an
individual’s own existence and being. The quality and
meaning of life and health can chan ge over time an d thus
be relative and not definite. According to Frankl [14]
each human being should seek and realise certain per-
sonal meaning in life, which implies more than merely
satisfying certain urges or instincts.
“Good health” is a major resource for social, economic
and personal development and is an important dimension
of the quality of life [15]. Health is also a phenomenon
that is difficult to measure as it consist of both subjective
and objective dimensions [16].
Quality of life after a specific event is assessed on the
basis of one’s previous life, at the time when it is meas-
ured is usually seen in relation to the quality of life that
has been experienced earlier and in this way it is a sum-
ming up until the measurement takes place. Quality of
life is therefore assessed from various perspectives and
cannot only be made with reference to a single event, in
this case an AAA operation. Although the instruments
have been validated for measuring Health Related Qua-
lity of Life, it is necessary to consider a range of different
aspects and events that exert an influence on the individual.
2. Methods
2.1. Study Design
An explorative quantitative design was used in which
HRQoL was measured by the instruments Nottingham
Health Profile (NHP) and Short Form 36 (SF-36). The
combination was used since it has been indicated that
SF-36 might give less skewed distribution of answers,
while NHP might be more sensitive for changes in h ealth
status and changes of HRQoL over time [17]. The ques-
tionnaires were answered before operation (Baseline), 1,
12 and 24 months after surgery. A g ender and age m a t c h e d
reference group was used for SF-36 as a comparison with
the study groups. In one vascular unit the patients were
invited to participate in the study when they came to the
department for vascular surgery. After one month, one and
two years, the questionnaires were sent to their home
address. In the other vascular unit the questionnaires w ere
sent by post at all occasions, including the preoperative
evaluation.
2.2. Instruments
Short Form-36 (SF-36)—is a Health Related Quality of
Life instrument developed by Ware & Shelbourne (1992)
to measure physical and Mental Health. The SF-36 is stand-
ardised within the framework for the quality of life as-
sessment [18]. The instrument includes 36 items that as-
sess eight areas of health: Physical Functioning (PF), Role
limitations due to Physical health problems (RP), Bodily
Pain (BP), Social Functioning (SF), Vitality (V), Mental
Health (MH), Role limitations due to Emotional health
problems (RE) and General Health perceptions (GH).
Scores are coded for each area. The sum is calculated and
transformed to a scale ranging from 0 - 100. A total score
of 100 indicates the best possible state of health. The
figures from these eight areas can also be summarized to
either a score of the physical component (Physical Com-
ponent Score, PCS) or the mental component (Mental
Component Score, MCS). SF-36 has been tested for both
internal and external vali dity as wel l as reliability [19,20].
Nottingham Health Profile (NHP)—was developed
from the earlier Nottingham Health Index [21]. The aim
of the instrument is to measure the consequences in daily
life of a reduced function. The instrument is divided into
two main parts: Part 1 (38 questions) covers: Energy,
Emotional reactions, Physical mobility, Sleep, Pain, and
Social isolation. Part 2 (7 questions) covers: Paid employ-
ment, Housework, Family relationships, Social life, Sex
life, Hobbies and Holid ay.
The scores range from 0 - 100, with a higher score in-
dicating a higher level of distress or impairment (oppo-
site to SF-36). The test-retest reliability of the NHP has
been investigated through correlations with a four week
interval, showing a high Spearman coefficient for the
separate domains [ 22].
2.3. Subjects
The inclusion criteria were: Being able to express and
understand the Swedish language, mentally clear, diagnosed
having AAA and acceptance to participate in the study.
Totally 70 subjects were consecutively invited from a
University hospita l in Sweden (A) and 14 of these d ec li n e d
participation (6 planned for EVAR and 8 OR). The total
number of included subjects from hospital A, were 56.
Twenty subjects were included from a University hospi-
tal in Sweden (B) adding up to a total number of 76.
More men were included in the stud y (n = 63/76, 83%)
reflecting that AAA is more common among men com-
pared to women [23]. Baseline characteristics are descri b e d
in Table 1. The mean age for all subjects was 72.5 (range

M. PETTERSSON ET AL.
438
52 - 85 years).The subjects in the OR group were signifi-
cantly younger compar ed to the EVAR group (p < 0.001 ).
No other significant differences in baseline characteris-
tics were found between the two groups.
The postoperative response rates for OR and EVAR
were 87.5% versus 91.7% at 1 month, 92.5% versus 83 . 4 %
at 12 month, 86% versus 90% at 24 month.
Eighty-eight percent (67/76) of the subjects could be
followed until two years. In the EVAR group two pa-
tients died after one year (one each from cancer and heart
disease). Two patients in the OR group died; one at one
month due to heart problems and the second patient after
two years of an unknown cause. The other drop-outs we re
related to no return of the questionnaires.
2.4. Ethics
All subjects were thoroughly informed about the aim of
the study and their right to decline participation when-
ever wanted. The study was approved by the Ethical Re-
search Committee at the Sahlgrenska Academy, Univer-
sity of Gothenburg, Sweden (S 712-02).
2.5. Statistical Methods
Mean and standard deviation (SD) were used to describe
the material. Two-side p-value was used to prove sig-
nificances. A p-value of p < 0.05 was considered signifi-
cant. Fisher’s permutation test was used to test if there
were any significant differences between the OR and
EVAR groups at baseline and to calculate significant
changes of variables between the two groups. Fisher’s
test for paired comparisons was used in order to calculate
significant changes of variables over time within each group.
This is equal to each group being its own control. T-test
was used to see if there where any significant differences
between th e EVAR and OR group and the matched group
at baseline and after two years. The measurements have
not been performed on individual level.
Table 1. Age, gender, risk factors and p-values in the two
groups: Endovascular Aneurysm Repair (EVAR n = 36) an d
Open Repair (OR n = 40).
EVAR n = 36 OR n = 40 p-value
Mean age 75 68 0.001
Range age 65 - 85 52 - 80
Male 32 31 >0.30
Female 4 9 0.30
Male mean age 74 67
Female mean age 78 72
Cerebral vascular disease 6 7 >0.30
Cardiovascular disease 13 22 0.19
Renal disease 4 7 >0.30
Hyper tension 19 25 >0 .30
Previous vascular operations 7 15 0.16
Pulmonary diseas e 6 3 >0.30
Diabetes 4 3 >0.30
Linear regression was used in order to investigate if
any difference in age affected the comparison between
the two groups. Mantels statistical test [24] was used to
test if differences in pain might have affected the result.
A gender and age matched reference group were ran-
domly picked out with a two years interval from the
Swedish SF-36 standard database. For the description of
the matched reference group, see Swedish manual and
interpretation guide [25]. The mean values for the age
and gender matched reference group are described for the
SF-36 domain. This reference group was only used as
comparison with the study groups for the SF-36 instru-
ment. Statistical analyses were performed using the com-
puter program SPSS version 12.0.
3. Results
The hospital stay for the OR group was on average 10
days (range 5 - 17) and for the EVAR group 6 days
(range 3 - 15). The aneurysmal average size before the
operation was for OR 61.5 mm and for EVAR 61.2 mm.
There were no significant differences in risk factors
between the EVAR and OR group at baseline. There we re
no significant differences between the two hospitals in
patient’s age or risk factors. No differences emerged at
baseline in the various domains of the SF-36 and the
NHP with the exception o f pain. The use of Mantels sta-
tistical test showed that these differences had no influ-
ence on the result. Pain and age showed no correlation.
No symptoms from the aneurysm were reported by 77%
(n = 57) of the p atients.
Comparisons of OR and EVAR groups and the refer-
ence (age and gender matched) group are presented at
first and thereafter differences within the groups (EVAR,
OR) and between the groups.
3.1. Comparisons of OR and EVAR Groups and
the Matched Reference Group (Age and
Gender Matched Group)
Baseline: The EVAR group rated their health status sig-
nificantly lower in the domain of Mental Health (p < 0.02)
and MCS (p < 0.002) in relation to the matche d reference
group. This was similar to the OR group who rated their
health status significantly lower in Mental Health (p < 0. 04),
Role Physical (p < 0.01) and Role Emotional (p < 0.03).
Two years: EVAR group rated thei r health stat us similar
to preoperative status except a significant improvemen t in
the domain of Bodily Pain (BP). The OR group had a ten -
dency to estimate their health to be improved in all do-
mains after two years compared to the reference group
but only in BP (p < 0.02) and the Physical Component
Score (p < 0.04) reached significance.
All mean values for EVAR and OR over time in rela-
tion to the matche d reference gro up in the SF-36 domain
are illustrated in Figures 1-8.

M. PETTERSSON ET AL. 439
Physi cal f unct i on
0
10
20
30
40
50
60
70
80
90
100
Basel i ne1 mont h1 y ear 2 year
Score
EVAR
EVAR RG
OR
OR- RG
Ge ner al he alt h
0
10
20
30
40
50
60
70
80
90
100
Bas el i ne1 month1
EVAR
EVAR RG
Score
OR
OR-RG
Figure 1. Changes in domains phy sical function (SF-36) ov er
time for OR and EVAR patients in relation to the matched
reference group (RG).
Role-physical
0
10
20
30
40
50
60
70
80
90
100
Ba seline1 mont h1 y e ar 2 year
Score
EVAR
EVAR RG
OR
OR-RG
Figure 2. Changes in domains r ole-physical ( SF-36) over time
for OR and EVAR patients in relation to the matched refer-
ence group (RG).
Bodily pain
0
10
20
30
40
50
60
70
80
90
100
Ba seline1 mon t h1 y ea r 2 y ea r
Score
EVAR
EVAR RG
OR
OR-RG
Figure 3. Changes in domains bodily pain (SF-36) over time
for OR and EVAR patients in relation to the matched refer-
ence group (RG).
3.2. SF-36—Comparisons within Each Group
After one month: A significant decrease could be seen
after one month compared to baseline in both the EVAR
y
ear 2
y
ea
r
Figure 4. Changes in domains general health (SF-36) over
time for OR and EVAR patients in relation to the matched
reference group (RG).
V
itality
0
10
20
30
40
50
60
70
80
90
100
Baseline1 month1
EVAR
EVAR RG
Score
OR
OR-RG
y
ear 2
y
ea
r
Figure 5. Changes in domains vitality (SF-36) over time for
OR and EVAR patients in relation to the matched reference
group (RG).
Soci al function
0
10
20
30
40
50
60
70
80
90
100
Ba seline1 mont h1 year 2 y ear
Score
EVAR
EVAR RG
OR
OR RG
Figure 6. Changes in domains social function (SF-36) over
time for OR and EVAR patients in relation to the matched
reference group (RG).
and OR groups in Physical Functioning, Role Physical,
Vitality and Bodily Pain. The OR group exhibited a sig-
nificant decrease in the Social Functioning domain after
one month, something not observed in the EVAR group.

M. PETTERSSON ET AL.
440
0
10
20
30
40
50
60
70
80
90
Baseline1 month1 year 2 year
Score
EVAR
EVAR RG
OR
OR-RG
Role-emotional
Also the general Physical Component Score decreased
after one month in both groups while the Mental Com-
ponent Score only decreased significantly in the OR group.
After one year: The EVAR group (n = 32) showed a
significant improvement in the Role—emotional domain
(p < 0.022) compared to baseline. An improv ement in the
domain Mental Health (n = 37, p < 0.014) and Role-
physical (n = 38, p < 0.025) was also evident in patients
operated with OR after one year compared with baseline.
After two years: An improvement in the Men tal Health
(n = 39, p < 0.001) and Role Physical (n = 35, p < 0.001)
was evident in patients operated with OR after two years
compared with baseline. No significant differences were
found in the EVAR group after two years. Physical Com-
ponent Score (PCS), improved for the OR group (p <
0.032) two years (n = 38) after surgery compared to base-
line. No significant differences were found in the EVAR
group in PCS after two years. The Mental Component
Score (MCS) showed a significant improvement in the
OR group from baseline until two years (n = 38, p <
0.014) after surgery. No si gnificant differences were found
in the EVAR group in MCS score at this time-point.
Mean, SD and p-value from the scores in SF-36 over ti me
(EVAR and OR) a re presented in Tables 2 and 3.
Figure 7. Changes in domains role-emotional (SF-36) over
time for OR and EVAR patients in relation to the matched
reference group (RG).
0
10
20
30
40
50
60
70
80
90
100
Ba seline1 mont h1
y
ear 2
y
ea
r
Score
EVAR
EVAR RG
OR
OR-RG
Mental health
3.3. Comparisons between Groups over Time
Significant differences were found between the groups
at baseline and after one month concerning: Bodily Pain
(p < 0.045), Vitality (p < 0.020) and Social Functioning
(p < 0.037) with benefit for EVAR. After one year, a
Figure 8. Changes in domains mental health (SF-36) over
time for OR and EVAR patients in relation to the matched
reference group (RG).
Table 2. Mean, SD and p-value in domains for SF-36 for patients treate d with OR (baseline, 1 month, 1 year and 2 years afte r
surgery). (PCS = Physical Component Score, MCS = Mental Component Score). Higher scores indicate higher health related
quality of life. A p-value < 0.05 compared to baselin e was considered si gnificant.
Variable Baseline 1 month 1 year 2 year
n Mean SD n Mean SD p-valuen Mean SD p-valuen Mean SD p-value
Physical
function 39 71.00 27.4734 64.60 24.470.0047** – 38 74.0525.65 >0.30 35 79.08 20.78>0.30
Role
physical 39 47.01 44.0335 17.86 32.97<0.001***
– 38 65.3538.580.025* + 35 77.86 36.26>0.001*** +
Bodily
pain 40 84.58 22.2635 57.09 26.38<0.001*** – 38 86.7619.90 >0.30 35 83.57 27.170.30
General
health 40 67.34 22.3136 69.04 20.49>0.30 38 71.2221.68>0.30 35 72.14 21.19>0.30
Vitality 40 68.96 23.7435 45.57 22.19<0.001***
– 37 74.1918.91 0.084 35 71.71 21.72>0.30
Social
function 40 82.50 22.2536 61.46 27.61<0.001***
– 37 88.1818.62 0.095 35 90.36 18.710.060
Role
emotional 39 62.39 44.7135 47.62 47.340.081 34 71.5739.47>0.30 34 79.41 31.800.065
Mental
health 40 73.15 20.2435 70.74 22.62>0.30 37 82.4513.30 0.014* + 39 84.92 16.22<0.001*** +
PCS 39 44.42 11.1632 37.06 9.30<0.001***
– 34 46.6710.06 >0.30 38 48.95 9.050.032* +
MCS 39 46.63 12.2832 41.39 12.780.027*
– 34 51.078.670.065 38 51.54 9.230.014* +
+Improvement, –Dete ri or ation (*p < 0.05, **p < 0.01, ***p < 0.001).

M. PETTERSSON ET AL. 441
Table 3. Mean, SD and p-values in domains for SF-36 for patients treated with EVAR (baseline, 1 month, 1 year and 2 years
after surgery). (PCS = Physical Component Score, MCS = Mental Component Score). Higher scores indicate higher health re-
lated quality of life. A p-value < 0.05 compared to baseline was considered significant.
Variable Baseline 1 month 1 year 2 year
n Mean SD n Mean SD p-valuen MeanSD p-valuen Mean SD p-value
Physical
function 36 65.85 24.8133 57.99 26.000.0025** – 30 65.1425.74 >0.30 31 61.29 26.680.0825
Role
physical 36 52.08 45.6633 37.12 42.450.014* – 30 58.3344.20 >0.30 31 62.63 36.950.29
Bodily
pain 36 72.83 25.4733 62.42 27.370.020* – 31 73.3528.72 >0.30 31 77.23 26.50>0.30
General
health 35 62.14 21.8133 67.61 20.81>0.30 31 60.8921.470.18 31 63.51 17.98>0.30
Vitality 35 61.57 22.1832 52.97 21.250.0098**
– 31 59.0323.32 0.096 31 57.90 22.240.092
Social
function 36 81.94 19.7033 76.52 23.120.089 31 79.4429.15>0.30 31 81.85 25.17>0.30
Role
emotional 34 52.94 45.7832 52.08 44.75>0.30 31 70.4342.10 0.022* + 31 70.97 38.240.068
Mental
health 35 72.69 19.7532 72.41 20.89>0.30 31 74.3219.67>0.30 36 78.36 19.430.12
PCS 32 41.63 10.9631 37.99 10.920.0037**
– 30 41.3311.97 0.077 36 40.05 13.390.062
MCS 32 45.79 10.5131 45.42 12.22>0.30 30 48.3512.810.29 36 49.82 11.610.055
+Improvement, –Dete ri or ation (*p < 0.05, **p < 0.01).
sig nificant difference in Vitality (p < 0.015) was revealed,
to th e advantage of the OR group, while after two years a
benefit was revealed in the Physical Component Score
domain (p < 0.0056) for patients operated with OR, Ta-
ble 4.
3.4. NHP—Comparison within Each Group
After one month: Significant differences in relation to
baseline in the health status of the OR group were found
after one month in the following domains; Lack of en-
ergy p < 0.011), Pain (n = 36, p < 0.001), Physical mo-
bility (n = 36, p < 0.001), which was not observed in the
EVAR group. Overall NHP increased significantly in
patients operated on by means of OR (n = 36, p < 0.017)
after one month, meaning reduced HRQoL. No signifi-
cant differences were found in the EVAR group.
After one year: No significant differences were found
in the EVAR and OR groups between baseline and obser -
vations at one year. The result indicates that the OR-g r ou p
had recovered from the intervention.
After two year: The EVAR group reported a decline in
health status after two years in the domains Social isola-
tion (n = 31), p < 0.027) and Physical mobility (n = 31, p
< 0.020). The domain of sleep improved in the EVAR
group compared to baseline. No significant differences
were found in the OR group compared to baseline values.
3.5. Comparison between the Groups over Time
in NHP
After one month most domains demonstrated a significan t
change to baseline with OR which was not the case with
EVAR. Significant differences between the groups were
identified: after 1 month in the domain of Pain (p < 0.028)
with benefit for patients operated with EVAR. After 2
years a significant difference in sleep (<0.015) between
EVAR and OR was found in favour of patient operated
with EVAR. The total NHP-score was however in favour
of OR after 1 and 2 years, especially demonstrated with
pain, social isolation and physical mobility, Table 5.
4. Discussion
Aortic aneurysm is a serious diagnosis that may affect
patients’ whole life. This study shows that Mental Health
is worse for patients with diagnosed AAA in relation to
an age and gender matched population. Two years after
surgery patients have similar scores as the matched ref-
erence group, and within the domain of Physical Com-
ponent Score, patie nts who we re ope rated wit h OR reported
even better health. Consequently surgery for AAA must
be considered as a benefit from a HRQoL perspective.
HRQoL should therefore be considered to be part of the
de ci sion making besides aneurysmal diameter. The ave r a g e
age in this study emerged from the consecutive inclusion.
It is possible th at the re su lts o f th is stu dy wou ld hav e been
d iff erent if it had been a younger population. In this s tud y,
however, each group was also its own reference when
comparisons were made. Dick et al. (ref nr) showed, in a
study with a larger number of subjects (compared to our
study) that long-term HQoL measured by the SF-36 after
EVAR and OR, that scores in all age gr oup s w ere sim ila r
to an age-and sex-adjusted stand ard population.

M. PETTERSSON ET AL.
442
Table 4. Fischer’s permutation test for pair significant com-
parisons between the two groups OR and EVAR (SF-36)
(p-values between the group). From baseline to 1 month, 1
and 2 year after surgery. In the domain of bodily pain, vita-
lity and social function it was a benefit for the EVAR group
after 1 month. After 1 year, a signific ant differ ence in vitality
was revealed, to the advantage of the OR grou p, while after 2
years a benefit was revealed in the phy sical component score
domain for patients operated with OR.
Variable 1 month 1 year 2 year
Psychical function >0.30 >0.30 0.12
Role-psychical >0.30 >0.18 0.16
Bodily pain 0.045* >0.30 >0.30
General Health >0.30 0.20 >0.30
Vitality 0.020* 0.015* >0.30
Social function 0.037* 0.094 >0.11
Role-emotional >0.30 0.021 >0.30
Mental-health >0.30 >0.18 0.29
PCS 0.18 0.13 0.0056*
MCS 0.25 >0.30 >0.30
Table 5. Fischer’s permutation test for significant compari-
son between the two groups EVAR and OR (NHP) (p-value s
between the groups). From base line to 1 month, 1 and 2 year
after surgery. In the domain of pain after 1 month and sleep
after 2 years it was a benefit for the EVAR group.
Variable 1 month after 1 year after 2 year after
Emotional 0.27 >0.30 >0.30
Sleep >0.30 >0.30 0.015*
Energy 0.21 0.15 >0.30
Pain 0.028* >0.30 0.21
PM 0.093 >0.30 0.17
Social isolation >0.30 >0.30 >0.30
NHP total 0 .18 >0.30 >0.30
NHP 2 0.30 >0.30 >0.30
This prospective study had a high response frequency
and few cases lost for follow-up. Some of the patients in
the study had foreign backgrounds but since they could
speak and understand the Swedish language, we have not
identified them from the rest of the group. It is a weak-
ness that patients with different origins and who not can
speak and understand the Swedish language not are rep-
resented in this study when we have an increasingly mul-
ticultural society and this is something to consider in
future studies. The study indicates that patients in the
EVAR group reported a better HRQoL in the short time
perspective when compared to OR patients but, after one
and two years after the intervention, the measurements
(SF-36) revealed that the OR group had an improved
HRQoL in several domains, which was not the case with
EVAR. These findings were strengthened by the NHP
measurement where the EVAR group showed a decline
in HRQoL after two years in the areas of Social isolation
(SO) and Physical mobility ( PM), which was not evident
in the OR group. The finding that patients in the EVAR
group reported impaired HRQoL two years after the in-
tervention could be explained by the fact that annual
medical follow-ups may keep patients in an uncertain
position, reminding them of the vulnerability of life and
the intervention.
Our study revealed that OR patients exhibited a sig-
nificant improvement in the Mental Health domain after
one and two years, which was not the case with the EVAR
patients and thus agrees with the findings of Aljabri et al.
2006.
Several studies have shown that shortly after the op-
eration OR patients have a poorer HRQoL in several
domains compared to EVAR patients [4-10]. In the pre-
sent study overall NHP showed a significant decreased in
HRQoL in the OR groups but not in EVA R group at one
month. As mentioned a different situation seems to be
present in the long term perspective. In a randomized
study by Prinssen et al. 2004 [9], which included 153
patients, it was found that OR was associated with a sig-
nificantly higher HRQoL at one year following treatment
in the domains of Social function (SF), Role Emotional
(RE) and Mental Health. This result is in accordance
with findings in our study, which also showed an im-
provement in Mental Health from baseline to one and
two years after surgery for patients treated with OR.
One HRQoL aspect which is not specifically covered
in this study is the impact on sexual function. It has pre-
viously shown that this part of the HRQoL is affected
similarly with a significant deteriorated function over time
with EVAR but not OR [26]. EVAR-1 stated that no dif-
ferences in HRQoL had been observed among patients
after 1 - 24 months. This study showed that EQ5D (Eu-
roQol) scores were similar in both groups and to age-
matched and sex-matched population norms. At 12 - 24
months after randomization there was no difference be-
tween the groups. HRQoL were secondary endpoints in
this study.
The results in EVAR-1 reported only MCS and PCS
and not specific for the different domains in SF-36. Ther e
were no final observations of the Health Related Quality
of Life two years after surgery. Point of times for report-
ing were, 0 - 3, 3 - 12 and 12 - 24 months which unfor-
tunately gives a poten tial of spread of the responses over
time. HRQoL differs over time, as shown in the present
study, which might have influenced the conclusions in
EVAR-1.
In our study patients where not randomly assigned for
OR or EVAR. Instead the respondents were invited con-
secutively. Patients might have been operated with EVA R
due to the fact that their medical condition was too poor
for an OR. However, risk factors and characteristics did
not differ between the groups.
The interviews with the patien ts revealed that their health

M. PETTERSSON ET AL. 443
status is affected by many other conditions that are not
related to the aneurysm. On the other hand the additional
questions, which can be considered more disease specific,
revealed that the majority of OR patients experienced the
operations as a difficult event. This agrees with the
Health Related Quality of Life instruments that ind icated
a greater decrease in the perception of health a short time
after the OR compared to the patients in the EVAR group.
There are some limitations that must be considered w h en
discussing the results. There was a significant difference
in age in our study. The patients operated with EVAR
were older than the OR group, which obviously can have
consequences for the results. However, this fact was t ak en
into account when performing the statistical analyses and
each group has been its own control. The relative change
within each group has been used for comparisons betwe en
EVAR and OR. In another study where the EVAR group
also were older than their OR counterparts the EVAR
group reported a poorer health quality of life six months
after the operation co mpared to the OR patients [10].
Another weakness of this study is that we have not
taken into account the subjects’ social network and cog-
nitive status, and we have not investigated the subjects’
asset of supportive next of kin. Such factors may have an
impact on the perceived Health Related Quality of Life.
HRQoL after a specific event is assessed on the basis
of one’s previous life, as this is the only way in which the
present life situation can be evaluated. Although the in-
struments have been validated for measuring quality of life,
it is necessary to consider a range of different aspects and
events that exert an influence on the individual and re-
sponses to questionnaires. Therefore caring in conjunction
with prospective follow ups should bring these issues
concerning health and quality of life up and in that way
alleviate worries and other discomforts. This presupposes
of course an establishment of a caring relationship [27].
The conclusions we have drawn are based on a small
number of subjects, however the number of subjects in-
cluded in the study are similar to previously published
studies [4-10].
5. Conclusions
Mental Health seemed to be impaired in AAA patients in
relation to a matched reference group. This difference is
not present two years after intervention.
In the short term (one month) perspective, HRQoL
seems to be worse for the OR group than the EVAR group.
In the long term perspective however (one and two years),
there were significant improvements compared to preop-
eratively values in the OR group in the domains; Role-
physical and Mental Health and in the Physical Compo-
nent Score (PCS) and the Mental Component Score
(SF-36), which was not seen with EVAR. The NHP-
score was also in favour for OR after one and two years.
In summary the mental quality of life improves for AAA
patients independent of treatment modality. In the short
time perspective OR is worse than EVAR. After one and
two years the patients subjected to OR have better
HRQoL than EVAR patients compared to their baseline
values. The OR patients also seem to mentally include
their treatment in the general life to a higher degree at
later stages.
Relevance to Clinical Practice
Consequences of OR seem to affect physical well-being
in another way for OR patients than for patients where
the EVAR method was used. The findings from this stud y
are important for further development of the care plans.
Time for conversation about patient’s experiences, ques-
tions and thoughts during the process, but also in the pre-
operative phase is important for preventing a decrease in
Health Related Quality of Life both before and after sur-
gery.
6. Acknowledgements
The Vascular Surgery in west Sweden and Odd Fellow
Logen 129, Klarälven, Sweden supported the study. The
authors are grateful to the patien ts for participation in the
study.
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