Letter by De Rango et al Regarding Article, “Predictors of Abdominal Aortic Aneurysm Sac Enlargement After Endovascular Repair”

Abstract

HomeCirculationVol. 125, No. 5Letter by De Rango et al Regarding Article, “Predictors of Abdominal Aortic Aneurysm Sac Enlargement After Endovascular Repair” Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBLetter by De Rango et al Regarding Article, “Predictors of Abdominal Aortic Aneurysm Sac Enlargement After Endovascular Repair” Paola De Rango, MD, PhD, Piergiorgio Cao, MD, FRCS and Fabio Verzini, MD, PhD Paola De RangoPaola De Rango Search for more papers by this author , Piergiorgio CaoPiergiorgio Cao Search for more papers by this author and Fabio VerziniFabio Verzini Search for more papers by this author Originally published7 Feb 2012https://doi.org/10.1161/CIRCULATIONAHA.111.040840Circulation. 2012;125:e340To the Editor:Schanzer et al1 provided an essential message for current practice of endovascular aortic aneurysm repair (EVAR) outside randomized clinical trials. Their study clearly confirmed the strong influence of patient and morphology selection when deciding to proceed with EVAR: the liberalization in anatomic EVAR criteria observed in more recent years inevitably results in worse outcome. This message is important, especially today, when new-generation devices are increasingly expanding the indications for EVAR in adverse anatomies.The authors provided a picture of the real world of EVAR in the United States, but, in our opinion, several factors may confound interpretation of their findings: The inclusion criteria of the study by Schanzer et al required that patients undergo at least 1 computed tomography (CT) study after EVAR. In the real world, especially during recent years, not all patients undergo routine CT follow-up after EVAR. It is common that ultrasound, clinical visits, and no other examination are performed. Therefore, the authors should be aware that a selection bias may have occurred, leading them to reexamine CT scans only for those patients who have post-EVAR complications (endoleak, sac expansion, migration), and who were therefore sent for centralized review and further imaging evaluation (also because CT reading from M2S database is an expensive adjunct to the follow-up burden).The authors suggested that the rate of 41% sac enlargement at 5 years after EVAR may have been even underestimated, because a number of patients could have died before detection of sac enlargement. This is the worst scenario. But we believe that there may be also a best scenario in which the procedures were successful and most patients were doing well and, therefore, did not undergo a CT scan. In this scenario, a large number of patients with no post-EVAR sac enlargement could have been missed. According to this scenario, expansion rate might have been overestimated, because a wrong number of patients at risk was reported as the denominator.In our opinion, there may be a number of reasonable reasons to explain the raised alarm regarding the 59% application of EVAR in patients with aneurysm diameter <5.5 cm, such as the presence of coexisting large iliac aneurysms or the acceptance of a threshold of 5.0 cm to operate on an abdominal aortic aneurysm, as suggested by some trials (Open Versus Endovascular Repair [OVER], Dutch Randomized Endovascular Aneurysm Management [DREAM]) and applied in many centers.2,3 Furthermore, as the authors also emphasized, the CT scans reviewed in their study may have been performed before a diameter increase occurred; measurements were based a single CT scan before EVAR without any timing limitation. The CT scan could likely be months older than the repair, because it was performed during a surveillance program.Even though the aneurysm sac freedom from enlargement after EVAR was statistically lower in patients outside the instruction for use, the differences in the 5-year rates between the inside and outside instruction for use abdominal aortic aneurysm seem to be of limited clinical relevance (conservative instruction for use, 56.5% versus 61.0%; liberal and time-dependent instruction for use, 57.5% versus 59.1%).In conclusion, the article is suggesting an important warning message, but we believe that more convincing and clear information should be provided to give a picture of the real-world practice and strengthen the relevance of patient selection for EVAR.Paola De Rango, MD, PhD Unit of Vascular and Endovascular Surgery Hospital S.M. Misericordia Perugia, ItalyPiergiorgio Cao, MD, FRCS Unit of Vascular Surgery Department of Cardiosciences Hospital S. Camillo-Forlanini Rome, ItalyFabio Verzini, MD, PhD Unit of Vascular and Endovascular Surgery Hospital S.M. Misericordia Perugia, ItalyDisclosuresNone.