Endo-exuberance and abdominal aortic aneurysm management: have we gone too far?

Abstract

Hypothesis: new technology, such as endovascular abdominal aortic aneurysm repair (EVAR) may promote an ‘irrational exuberance’ for its application. Methods: nonsuprarenal AAA repairs performed at a single institution over a 7 year period were retrospectively studied. Method of repair, 30-day mortality and EVAR aortic neck anatomy were assessed. Results: 431 AAA repairs were performed between January 1996 and June 2002, 238 (55%) open and 193 (45%) EVAR. The percentage of EVAR increased steadily from approximately 20% in 1996 and 1997 to a peak of 69.5% in 2000. However, in 2001–2002 the percentage of EVAR fell to approximately 40% of total repairs. In this time period our selection criteria for EVAR became more conservative, with treatment of fewer patients with short aortic necks (12.8 vs. 28.9% with neck length ≤ 20 mm, p = 0.05; 3.8 vs. 10.8% with neck length ≤ 15 mm, p = 0.1) or highly angulated necks (3.8 vs. 28.9% with neck angulation ≥ 40 degrees, p = 0.04) in 2001–2002 versus 1999–2000, respectively. Institutional volume of AAA repairs doubled over the study period (p = 0.001). 30-day mortality over the study period for nonruptured EVAR and open AAA repair was 2.6 and 3.3%, respectively (p = NS). The complexity of open repairs increased significantly during the final 3 years of the review. Conclusions: the application of EVAR has fallen from a high of 69.5% of our AAA repairs in 2000 to approximately 40% in 2001–2002. More prudent patient selection in recent years regarding unfavorable aortic neck anatomy was felt to be a primary etiology of changes in overall EVAR utilization. The anticipated improvement in long-term results from EVAR await multi-year follow-up.