Endovascular Aneurysm Repair

Abstract

Since first described by Parodi in 1991, endovascular aortic repair (EVAR) has progressively and dramatically changed the approach to treating abdominal aortic aneurysm (AAA) disease.1 Whereas historically developed to treat patients unfit for open repair, EVAR now represents the primary paradigm by which most infrarenal AAAs are managed. This paradigm shift has occurred in the setting of long-term clinical uncertainty and increased expense, largely secondary to the costs of the endograft itself. EVAR is currently performed by multiple interventional and surgical specialties. Outcomes are associated with lower in-hospital mortality rates compared with open repair, often permitting successful discharge of patients within 24 hours. Because the market share of EVAR has increased, the endograft industry has also seen tremendous growth and development. Cross-sectional imaging with 3-dimensional reconstructions has become paramount to the appropriate and timely management of aortic aneurysms. At present, even in the setting of aortic rupture, EVAR is preferred because it has been associated with lower mortality rates compared with open repair. Despite the rampant increase in EVAR, not all patients are anatomic candidates for EVAR as defined by industry-issued instructions for use. Therefore, alternative treatment strategies, such as altering endografts with fenestrations or sidearm grafts, snorkeling stent grafts alongside endografts, or performing hybrid debranching procedures with open bypasses to the viscerals and renals followed by endografting have been developed. Although the data supporting EVAR as the primary treatment option for infrarenal AAA is robust, its superiority over open repair can be questioned until the long-term outcomes (>10 years) from landmark randomized controlled trials begin to surface. Parenthetically, the indications for EVAR seem to be increasing because clinical equipoise remains ambiguous and fewer trainees are required to perform open AAA repair. Although early use of EVAR was primarily at centers of excellence, currently it has become the most …