Endovascular aortic repair or minimal incisional aortic surgery: Which procedure to choose for treatment of high-risk aneurysms?

Abstract

Conclusion: Endovascular aneurysm repair (EVAR) and minimal incision aortic surgery (MIAS) give comparable results for the treatment of high-risk patients with aneurysms. Summary: The authors investigated the comparable efficacy of EVAR and MIAS in the treatment of high-risk patients with infrarenal aortic aneurysms. EVAR was performed using standard techniques. MIAS was performed through a small midline incision (8 to 12 cm) with intra-abdominal visceral retraction. A hand-sewn aortic anastomosis was performed. This was a retrospective review of patients treated with EVAR or MIAS between 2000 and 2002. Patients were thought to be high-risk based on age >80 years, creatinine >3.0mg/dL, recent myocardial infarction, history of congestive heart failure, severe pulmonary disease, hostile abdomen, or morbid obesity (BMI>30). Exclusionary criteria for EVAR were an aneurysm neck <1.5 cm in length or >26 mm in diameter, the presence of densely calcified iliac arteries (<6 mm), or a serum creatinine >3.0 mg/dL. Patients were excluded from MIAS for the presence of perirenal abdominal aortic aneurysm, morbid obesity, and aneurysm diameter >10 cm. Data analyzed included demographics, morbidity, mortality, and duration of stay. Of the 84 patients in the study, 61 were treated with EVAR and 23 were treated with MIAS. The average age was 72 years for MIAS and 74 years for EVAR. The average aneurysm size was 6 cm in both groups. American Society for Anesthesiologists score was 3.0 for MIAS patients and 3.1 for EVAR patients. Two risk factors were present in 52% of EVAR patients and in 30% of MIAS patients. Three risk factors were present in 20% of EVAR patients and in 30% of MIAS patients. Two deaths (3%) occurred in the EVAR group and one (4%) in the MIAS group. Average operative stay was 5.1 days for both groups. Thirty-day morbidity was 18% for EVAR and 17% for MIAS. Comment: The Wisconsin group has acquired considerable experience with both EVAR and MIAS. The current study suggests EVAR and MIAS are comparable in the high-risk aneurysm population. The authors, however, continue to dance around performance of a randomized trial in their institution. They appear to have both the expertise and the patients to perform such a trial, and it is probably time to do so.