Re: ‘Systematic Review and Meta-Analysis of Long-Term Survival After Elective Infrarenal Abdominal Aortic Aneurysm Repair 1969–2011. Five Year Survival Remains Poor Despite Advances in Medical Care and Treatment Strategies’

Abstract

Strategies’ A recent systematic review by Bahia and coworkers have reported poor 5 year survival after elective abdominal aortic aneurysm (AAA) repair, in spite of advances in surgical techniques and operative procedures over recent decades. The mean 5 year survival following AAA repair continues to be lower than expected and the aim of AAA repair to prolong survival by means of prevention of rupture does not result in a longer life expectancy. 1 We should not be surprised by these results for two main reasons. Firstly although many candidates for AAA repair are affected by multilevel atherosclerotic lesions, and coexisting coronary artery disease (CAD) represents the major cause of late death following AAA repair, current guidelines consider most patients eligible for surgery on the basis of simple clinical risk stratification without further cardiac evaluation. Few patients undergo routine coronary angiography preceding aortic surgery. Secondly, as CAD continues to be a clinical burden that offsets the long-term benefit of surgery, the current strategy based on pre-operative risk stratification must be considered incompletely effective in the improvement of long-term survival after AAA repair. In patients scheduled for AAA repair more effort should be made to uncover CAD pre-operatively using the optimal coronary strategy regardless of pre-operative risk stratification, and this issue should be adequately addressed. Moreover, staged myocardial revascularization and AAA repair are currently associated with low procedural risk. A significant improvement in long-term survival (>90%) may be achieved by a systematic strategy of prophylactic coronary angiography and revascularization, as reported by a recent randomized trial and observational study. 2 We are firmly convinced that routine coronary angiography should be advocated for most candidates for aortic surgery who will mainly benefit from prophylactic revascularization during long-term follow up.