Invited commentary

Abstract

Skepticism is defined in the dictionary as doubt or unbelief. This noun has been in existence much longer than endovascular aneurysm repair (EVAR), but this word has been used since Parodi's original description of the less invasive abdominal aortic aneurysm repair. In fact, a little more than a decade after Parodi published his seminal work, the scientific literature still had skeptics. In 2001, Collin and Murie published an article in the British Journal of Surgery entitled “Endovascular treatment of abdominal aortic aneurysm: a failed experiment.” As a specialty, we have clearly evolved since this 2001 publication and have overcome much of the early skepticism surrounding EVAR, but open aneurysm repair still has a place as the “gold standard” for durability despite the increased perioperative risks. Can EVAR durability be improved to mimic open repair? Muhs et al are trying to answer that question with an adjunct to current EVAR technology analyzed in their manuscript as part of the Aneurysm Treatment Using the Heli-FX Aortic Securement System Global Registry (ANCHOR). I demonstrated skepticism of this manuscript. To be specific, I was concerned about the data presentation, especially the aneurysm sac regression. The authors studied the use of EndoAnchor (Medtronic, Santa Rosa, Calif) technology as an adjunct to EVAR with an analysis of 2-year follow-up in a propensity-matched cohort model. Although not statistically significant, there was a trend toward lower type Ia endoleaks, freedom from neck dilation, and freedom from aneurysm sac enlargement in the EndoAnchor group compared with the control group. I do not find the data concerning. In fact, it is possible that longer follow-up analysis will demonstrate a statistical significance for these three factors in the matched analysis. More impressive and maybe difficult to understand (thus, the skeptic in me that I mentioned earlier) is the sac regression data for the EndoAnchor patients. Approximately 81% of EndoAnchor patients experienced sac shrinkage compared with approximately 49% of the matched cohort, thus my confusion and skepticism based on the neck data and type Ia endoleak rate data mentioned before. The authors explain the sac regression well in their discussion based on two important EVAR characteristics of neck diameter and pre-existing thrombus. Patients with larger infrarenal neck diameters and more thrombus burden experienced improved aneurysm sac shrinkage in the EndoAnchor cohort. This finding is clear in their data but is potentially difficult to understand as the type Ia endoleak rate is not statistically different. It appears that a patient with EndoAnchors more thoroughly decompresses the aneurysm sac and that EndoAnchors as an adjunct to EVAR may provide more pressure reduction. The authors recognize the limitations of a nonrandomized study and the lack of long-term follow-up, but I think my initial skepticism may have been unfounded. Finite element analysis and pressure-sensing technology may be able to confirm the authors' hypothesis of pressure reduction differences. Either way, the data seem to support that fact that aneurysm sac regression is improved in EndoAnchor patients in this series. Matched cohort comparison of endovascular abdominal aortic aneurysm repair with and without EndoAnchorsJournal of Vascular SurgeryVol. 67Issue 6PreviewThe objective of this study was to examine whether prophylactic use of EndoAnchors (Medtronic, Santa Rosa, Calif) contributes to improved outcomes after endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms through 2 years. Full-Text PDF Open Archive