Patient selection for endovascular abdominal aortic aneurysm repair.

Abstract

Because the US device trials were not randomized and were not matched for either anatomic or clinical criteria, we do not have Level I evidence of efficacy when endovascular treatments are compared with conventional aortic aneurysm (AAA) repair. Consequently, creating a clear, detailed algorithm for patient selection is not possible at this time. Instead, the decision to recommend one type of aneurysm repair over another is quite subjective, will vary from institution to institution, and is governed by a number of factors including anatomy, medical comorbidity, operator skills, and access to the devices. Ideally, the UK EndoVascular Aneurysm Repair, the Dutch DREAM Trial, and the French ACE Project, when completed, will provide more objective guidance for patient selection for each of the two procedures. These trials will not only compare the two operative approaches but will also evaluate best medical treatment in inoperable cases. Although I believe that young, healthy patients should have conventional repair, in properly selected patients, endovascular repair appears to be comparable to conventional repair, using rupture and death as end points within the first year after deployment. Because most patients, given a choice, would opt for the simpler, less invasive procedure, the fundamental question each of us must ask is how to select those most suitable for each of the two approaches given the limited data available. There are two distinct aspects to this recommendation—first, the physiologic condition of the patient, taking into account the patient’s life expectancy and his or her risk for conventional operation, and second, the anatomic factors that make endovascular repair possible or impossible, safe or risky. EARLY RESULTS OF ENDOVASCULAR ANEURYSM REPAIR Vascular surgeons are psychologically uncomfortable with palliation of aneurysms as opposed to cure, probably for good reason. Endovascular repair does not provide freedom from rupture in every case. Rupture has been reported in 25 patients in the AneuRx Trials (1,112 patients treated). In contrast to conventional repair, the need for lifelong surveillance is costly in dollars, staff resources, and patient time. Reintervention rates for a variety of problems are alarmingly high and over an intermediate time may result in longer cumulative hospital days and expenditures than conventional repair. The largest data set is the EUROSTAR registry begun in 1996. Voluntary reporting from 88 institutions deploying over 3,000 endografts indicates that the 30-day mortality rate is 2.1%, freedom from persistent endoleak at 18 months is 90%, the rate of rupture approaches 1.5% per year, and the conversion rate to open repair is 3% per year. The voluntary reporting requirements of this registry probably underestimate the incidence of complications, but the fact that the incidence of graft-related complications does not decrease over time is worthy of note and concern. Nonetheless, in an older, sicker population, any lack of certainty about a longterm cure after endovascular repair seems less relevant.