Adoption Of Endovascular Aneurysm Repair Research Articles

Kidney Function, Male Gender, and Aneurysm Diameter Are Predictors of Acute Kidney Injury in Patients with Abdominal Aortic Aneurysms Treated Endovascularly.

We retrospectively analyzed a prospective registry of abdominal aortic aneurysm of 247 patients operated endovascularly at a single center between 2015 and 2021. Due to a lack of clinical data, data of 192 patients were reviewed for postcontrast acute kidney injury. Additional comorbidities were included in this study: hypertension, diabetes mellitus, atrial fibrillation, chronic coronary syndrome, COPD, and chronic kidney disease. Follow-up examinations were performed before the procedure and 48 h after contrast administration. The group of 36 patients developed PC-AKI, which is 19% of the entire study population. Hypertension, diabetes, chronic kidney disease, male gender, and incidence of PC-AKI were more prevalent in patients with higher aortic aneurysm diameter ≥67 mm. In multiple regression analyses, independent predictors of PC-AKI were serum creatinine, chronic kidney disease, male gender, and aortic aneurysm diameter ≥67 mm. One of the major complications after EVAR is acute kidney injury, which is linked to higher death and morbidity rates. Independent risk factors for postcontrast acute kidney injury were chronic kidney disease, male gender, and aortic diameter. Only aortic diameter could be modifiable risk factor, and earlier surgery could be considered to yield better outcomes. More research is critically needed to determine how AKI affects long-term outcomes and to look at preventive options.

Multicenter Comparative Analysis of Late Open Conversion in Patients With Adherence and Nonadherence to Instructions for Use Endovascular Aneurysm Repair

Purpose: The widespread adoption of endovascular aneurysm repair (EVAR) as preferred treatment modality for abdominal aortic aneurysm (AAA) has enlarged the number of patients needing open surgical conversion (OSC). The relationship between adherence to Instructions For Use (IFU) and EVAR long-term outcomes remains controversial. The aim of this study is to compare preoperative differences and postoperative outcomes between EVAR patients not adjusted to IFU and adjusted to IFU who underwent OSC. Methods: This multicenter retrospective study reviewed 33 explanted EVARs between January 2003 and December 2019 at 14 Vascular Units. Patients were included if OSC occurred >30 days after implantation and excluded if explantation was performed to treat an endograft infection, aortic dissection, or traumatic transections. Variables analyzed included baseline characteristics, adherence to IFU, implant and explant procedural details, secondary reinterventions, and postoperative outcomes. Results: Fifteen explanted patients (15/33, 45.5%) were identified not accomplished to IFU (out-IFU) at initial EVAR vs 18 explanted patients adjusted (in-IFU). During follow-up, a mean of 1.73±1.2 secondary reinterventions were performed, with more type I endoleaks treated in the subgroup out-IFU: 16.7% vs 6.3% in-IFU patients and more type III endoleaks (8.3% vs 0%). Patients out-IFU had shorter mean interval from implant to explant: 47.60±28.8 months vs 71.17±48. Type II endoleak was the most frequent indication for explantation. Low-flow endoleaks (types II, IV, V) account for 44% of indications for OSC in subgroup of patients in-IFU, compared with 13.3% in patients out-IFU and high-flow endoleaks (types I and III) were the main indication for patients out-IFU (33.3% vs 16.7% in-IFU). Total endograft explantation was performed in 57.5% of cases (19/33) and more suprarenal clamping was required in the subgroup out-IFU. Overall, 30-day mortality rate was 12.1% (4/33): 20% for patients out-IFU and 5.6% in-IFU. Conclusions: In our experience, type II endoleak is the most common indication for conversion and differences have been found between patients treated outside IFU with explantation taking place earlier during follow-up, mainly due to high-flow endoleaks and with higher mortality in comparison with patients adjusted to IFU. Ongoing research is required to delve into these differences.

Association between surgeon case volume and years of practice experience with open abdominal aortic aneurysm repair outcomes

BackgroundWidespread adoption of endovascular aneurysm repair has led to a consequential decline in the use of open aneurysm repair (OAR). This evolution has had significant ramifications on vascular surgery training paradigms and contemporary practice patterns among established surgeons. Despite being the subject of previous analyses, the surgical volume–outcome relationship has remained a focus of controversy. At present, little is known about the complex interaction of case volume and surgeon experience with patient selection, procedural characteristics, and postoperative complications of OAR. The purpose of the present analysis was to examine the association between surgeon annual case volume and years of practice experience with OAR. MethodsAll infrarenal OARs (n = 11,900; elective, 70%; nonelective, 30%) included in the Society for Vascular Surgery Vascular Quality Initiative from 2003 to 2019 were examined. Surgeon experience was defined as years in practice after training. The experience level at repair was categorized chronologically (≤5 years, n = 1667; 6-10 years, n = 1887; 11-15 years, n = 1806; ≥16 years, n = 6540). The annual case volume was determined by the number of OARs performed by the surgeon annually (median, five cases). Logistic regression was used to perform risk adjustment of the outcomes across surgeon experience and volume (five or fewer vs more than five cases annually) strata for in-hospital major complications and 30-day and 1-year mortality. ResultsPractice experience had no association with unadjusted mortality (30-day death: elective, P = .2; nonelective, P = .3; 1-year death: elective, P = .2; nonelective, P = .2). However, more experienced surgeons had fewer complications after elective OAR (25% with ≥16 years vs 29% with ≤5 years; P = .004). A significant linear correlation was identified between increasing surgeon experience and performance of a greater proportion of elective OAR (P-trend < .0001). Risk adjustment (area under the curve, 0.776) revealed that low-volume (five or fewer cases annually) surgeons had inferior outcomes compared with high-volume surgeons across the experience strata for all presentations. In addition, high-volume, early career surgeons (≤5 years' experience) had outcomes similar to those of older, low-volume surgeons (P > .1 for all pairwise comparisons). Early career surgeons (≤5 years) had operated on a greater proportion of elective patients with American Society of Anesthesiologists class ≥4 (35% vs 30% [≥16 years' experience]; P = .0003) and larger abdominal aortic aneurysm diameters (mean, 62 vs 59 mm [≥16 years' experience]; P < .0001) compared with all other experience categories. Similarly, the use of a suprarenal cross-clamp occurred more frequently (26% vs 22% [≥16 years' experience]; P = .0009) but the total procedure time, estimated blood loss, and renal and/or visceral ischemia times were all greater for less experienced surgeons (P-trend < .0001). ConclusionsAnnual case volume appeared to be more significantly associated with OAR outcomes compared with the cumulative years of practice experience. To ensure optimal OAR outcomes, mentorship strategies for “on-boarding” early career, as well as established, low-volume, aortic aneurysm repair surgeons should be considered. These findings have potential implications for widespread initiatives surrounding regulatory oversight and credentialing paradigms.

The Clinical Utility and Assessment of Renal Biomarkers in Acute Kidney Injury After Abdominal Endovascular Aneurysm Repair. A Systematic Review.

The widespread adoption of endovascular aneurysm repair (EVAR) for abdominal aortic aneurysms (AAA) is due to the obvious advantages of the procedure compared to the traditional open repair. However, these advantages have to be weighed against the increased risk of renal dysfunction with EVAR. The evaluation of the perioperative renal function after EVAR has been hampered by the lack of sensitive and specific biochemical markers of acute kidney injury (AKI). The purpose of this study was to summarize all novel renal biomarkers and to evaluate their clinical utility for the assessment of the kidney function after EVAR. A systematic review of the current literature, as the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement guidelines, was performed to identify relevant studies with novel renal biomarkers and EVAR. Pubmed and Scopus databases were systemically searched. Studies reporting on thoracic endovascular aortic repair (TEVAR), case reports, case series, letters to the editor, and systematic reviews were excluded. Neutrophil-Gelatinase-Associated Lipocalin, Cystatin C, Liver-type fatty-acid-binding protein were the most common among the eligible studies while Interleukin-18, Retinol binding protein, N-acetyle-b-D-glucosaminidase and microalbumin have a sparse appearance in the literature. These biomarkers have been assessed in plasma as well as urine samples with each sample material having its own advantages and drawbacks. Which of these biomarkers has the most potential for assessing postoperative renal failure after EVAR, remains to be proved. The few studies presented in the literature show the potential clinical utility of these biomarkers, but larger studies with longer follow-up are required to determine the precise relationship between these biomarkers and postoperative acute kidney injury.

The Intricate Association Between Case Volume and Years of Practice Experience on Open Abdominal Aortic Aneurysm Repair

Widespread adoption of endovascular aneurysm repair has led to a consequential national decline in open aortic repair (OAR), affecting both vascular surgery trainees and established surgeons alike. Whereas the volume-outcome relationship has been studied extensively, little remains known about the complex interaction of surgeon experience vs case volume on patient selection, procedural characteristics, and postoperative complications associated with OAR. The purpose of this analysis was to define the interaction between surgeon years of experience and annual case volume on OAR outcomes.

Novel open technique for repair of endograft migration

Widespread adoption of endovascular aneurysm repair has led to increased incidence of late complications, such as endograft migration. Treatment options have to be tailored to the patient's health, quality of proximal aorta, and extent of migration. Complete or partial endograft removal is associated with significant morbidity and mortality. We describe a case in which open repair with endograft preservation was employed, with the additional benefit of a sutured proximal anastomosis.

Novel Open Technique for Repair of Endograft Migration

Abstract Widespread adoption of endovascular aneurysm repair has led to increased incidence of late complications, such as endograft migration. Treatment options have to be tailored to the patient's health, quality of proximal aorta, and extent of migration. Complete or partial endograft removal is associated with significant morbidity and mortality. We describe a case in which open repair with endograft preservation was employed, with the additional benefit of a sutured proximal anastomosis.

Invited commentary

In their article, Drs Hanley and colleagues describe a recent series from McGill University Health Centre and Jewish General Hospital in Montreal, Quebec. In this series, 110 patients were targeted for same-day discharge after endovascular treatment of their abdominal aortic aneurysm. Ultimately, 87 of these patients had a “successful” same-day discharge, raising some important questions about the feasibility and potential broader application of this concept. Could patients really go home on the same day as their aortic aneurysm repair? The authors took several important steps to try to smooth the pathway after an early discharge. Careful attention to social support, excluding those with major comorbidity or anatomically complex repair, and extra attention to early educational efforts were all likely to be important contributions toward a safe and early discharge among the 87 patients in whom this approach was successful. But what about the 23 patients who had complications after early discharge? One in five patients needed emergency department attention for potentially troublesome problems, such as access site complications or limb occlusions. Even among this highly select population, failure of same-day discharge occurred somewhat commonly. Early discharge is a laudable goal after surgery, as complications related to hospital-based care are common.1Makary M.A. Daniel M. Medical error—the third leading cause of death in the US.BMJ. 2016; 353: i2139Crossref PubMed Scopus (1726) Google Scholar Furthermore, early recovery after surgery programs have gained traction in other specialties,2Holm B. Thorborg K. Husted H. Kehlet H. Bandholm T. Surgery-induced changes and early recovery of hip-muscle strength, leg-press power, and functional performance after fast-track total hip arthroplasty: a prospective cohort study.PLoS One. 2013; 8: e62109Crossref PubMed Scopus (37) Google Scholar, 3Bardram L. Funch-Jensen P. Jensen P. Crawford M.E. Kehlet H. Recovery after laparoscopic colonic surgery with epidural analgesia, and early oral nutrition and mobilisation.Lancet. 1995; 345: 763-764Abstract PubMed Scopus (440) Google Scholar and spillover effects will likely affect the care of patients being treated for vascular disease. But a cautionary approach may be the best pathway forward for vascular patients facing endovascular aneurysm repair (EVAR). Mortality in most reports is <2% with EVAR, and an event such as hemorrhage related to access may contribute more potential morbidity and mortality if it occurs outside a hospital setting. Furthermore, payment mechanisms in the United States require a 24-hour hospital stay for remuneration after EVAR.4Warner C.J. Horvath A.J. Powell R.J. Columbo J.A. Walsh T.R. Goodney P.P. et al.Endovascular aneurysm repair delivery redesign leads to quality improvement and cost reduction.J Vasc Surg. 2015; 62: 285-289Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar, 5Stone D.H. Horvath A.J. Goodney P.P. Rzucidlo E.M. Nolan B.W. Walsh D.B. et al.The financial implications of endovascular aneurysm repair in the cost containment era.J Vasc Surg. 2014; 59: 283-290, 290.e1Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar Early reports of “safe” 24-hour discharge may have the unintended consequence of convincing payers that all patients could be discharged this rapidly after a major aortic intervention. This would very likely be too much, too soon. Safety and feasibility of endovascular aortic aneurysm repair as day surgeryJournal of Vascular SurgeryVol. 67Issue 6PreviewThe adoption of endovascular aneurysm repair (EVAR) during the past two decades has led to significantly shorter length of stay as well as lower hospital resource use. Currently, most patients are admitted to the hospital after EVAR; however, there are no standard observation periods, and timing of discharge is based on clinical judgment. The aim of this study was to confirm the safety and feasibility of performing EVAR as outpatient surgery. Full-Text PDF Open Archive

Invited commentary

Abdominal aortic aneurysm diameter is the primary factor that has been used to direct aneurysm therapy. Aortic morphologic characteristics have failed to have a demonstrable impact on clinical decision-making for several reasons. Foremost, the morphologic assessments must be readily available to clinicians, inexpensive, and easy to measure and have clinically defined thresholds that direct care. However, defining aneurysm morphologic features does have additional value beyond directing therapy. Clinicians, researchers, and engineers alike are constantly exploring the boundary conditions on which to base new medical treatments; these morphologic features can help direct new therapies. Advent and adoption of endovascular aneurysm repair have limited the opportunity to examine aortic wall tissue. In the current manuscript, Barrett et al monopolize the opportunity to subject harvested aortic aneurysm wall to mechanical stretch forces that parallel physiologic conditions. It is intuitive that degraded aortic wall will demonstrate varying degrees of stiffness and response to stress. However, it is uncertain which morphologic features affect those features. The authors reinforce the assumption that the aortic wall is subjected to extreme asymmetry when uniform stress is applied. Regions of high stiffness, marked by calcium deposition, are surrounded by vulnerable regions of low stiffness. The regions surrounding calcium are subjected to greater degrees of deformation, which translates to increased strains; in some regions surrounding calcium, the wall demonstrated two to four times the strain compared with reference regions. In addition, the authors demonstrated that stiff intraluminal thrombus also alters surrounding aortic wall mechanical properties similar to that of calcium. Regions of high strain also correlated with wall thinning and stretching visualized on electron microscopy. Interestingly, aortic diameter did not correlate with changes in aortic wall mechanics. Routine clinical imaging readily detects calcium burden within the aortic wall, and each patient demonstrates varying degrees of calcium within the aneurysm. The localized variation in aortic wall mechanics may provide additional information to identify patients at risk for rupture. In the future, this information may be used to adjust surveillance or to offer therapy, but for now, it will provide another boundary condition to better explain aneurysm wall mechanics and resultant aneurysm behavior. The opinions or views expressed in this commentary are those of the authors and do not necessarily reflect the opinions or recommendations of the Journal of Vascular Surgery or the Society for Vascular Surgery. On the influence of wall calcification and intraluminal thrombus on prediction of abdominal aortic aneurysm ruptureJournal of Vascular SurgeryVol. 67Issue 4PreviewParameters other than maximum diameter that predict rupture of abdominal aortic aneurysms (AAAs) may be helpful for risk-benefit analysis in individual patients. The aim of this study was to characterize the biomechanical-structural characteristics associated with AAA walls to better identify the related mechanistic variables required for an accurate prediction of rupture risk. Full-Text PDF Open Archive

Safety and feasibility of endovascular aortic aneurysm repair as day surgery

ObjectiveThe adoption of endovascular aneurysm repair (EVAR) during the past two decades has led to significantly shorter length of stay as well as lower hospital resource use. Currently, most patients are admitted to the hospital after EVAR; however, there are no standard observation periods, and timing of discharge is based on clinical judgment. The aim of this study was to confirm the safety and feasibility of performing EVAR as outpatient surgery. MethodsWe developed criteria to identify patients for potential same-day discharge (infrarenal aneurysm, low perioperative risk, to be accompanied for first 24 hours). We then implemented a prospective trial that observed patients planned for same-day discharge and compared them with a historical control group (patients who had undergone EVAR during the previous 2 years and met same-day discharge criteria). Basic demographic and operative data as well as length of stay, inpatient and perioperative complications, emergency department visits, readmissions, reinterventions, and deaths were collected. The primary outcome was the 30-day complication rate, and the study was powered to assess noninferiority. ResultsProspectively, we assessed 266 patients and planned 110 (41%) for outpatient EVAR (62% of historical controls met outpatient criteria). Demographic characteristics were similar between planned outpatients and historical controls. In planned outpatients, hospital stay was significantly shorter (0.7 ± 2.6 days vs 2.5 ± 6.9 days; P < .01), and 79% were discharged the same day of surgery. The 30-day follow-up was available for all study patients and 94% of control patients; there were no differences in complication (11% vs 9%), readmission (2% vs 4%), reintervention (4% vs 4%), or mortality (1% vs 1%) rates, but study patients had significantly more emergency department visits (15% vs 6%; P < .05). Unsuccessful same-day discharge was associated with longer operative times, increased blood loss, and use of general anesthesia. ConclusionsIn selected patients undergoing elective EVAR, same-day discharge is feasible without increasing complication rates. Health resource utilization remains a challenge in transitioning to an outpatient model.

Increasing Mortality Trends for Open Infrarenal and Thoracoabdominal Aneurysm Repairs in the Endovascular Era

Rapid adoption of endovascular aneurysm repair (EVAR) has been driven by improving trends in perioperative morbidity and mortality compared with open repair. Perioperative outcomes in the current era of anatomically more complex open repairs remain undetermined. The purpose of this study was to investigate trends for elective and ruptured aneurysm repairs and in-hospital mortality for these patients at a high-volume tertiary care, university teaching hospital. This study used an institutional, prospectively maintained database that derives all data from electronic hospital records, billing data, and patient charts to capture patients receiving either EVAR or open repair for abdominal aortic aneurysm (AAAs) and thoracoabdominal aortic aneurysms during an 11-year period between January 2004 and January 2015. There were 2753 aneurysm repairs performed throughout the study period; 1673 (60.1%) were open repairs, whereas 1080 (39.2%) were EVAR. In 2004, 29 EVARs were performed (14.9% of total aneurysm repairs), increasing to 110 repairs in 2014 (46.8%; Fig 1). Linear regression demonstrated an 11-year average increase in EVAR of 10.5 cases per year (R2 = 0.68), whereas open repair decreased by 5.2 cases per year (R2 = 0.73). Percentage of ruptured AAA repairs decreased from 11.3% in 2004 to 6.0% in 2014 with an increasing proportion performed by EVAR (9.1% in 2004 and 35.7% in 2014). Mortality for EVAR decreased from 6.9% in 2004 to 0.9% in 2014, whereas open repair mortality increased from 2.4% in 2004 to 6.4% in 2014 (Fig 2). Respectively, average mortality for elective EVAR and open repair was 3.5% and 2.7% from 2004 to 2007, 0.9% and 1.8% from 2008 to 2011, and 1.6% and 5.6% from 2012 to 2014. There is an ongoing transition favoring EVAR over open repair in the management of AAAs and thoracoabdominal aortic aneurysms, albeit a slower rate of adoption at our center. Notably, there is an evident trend toward increasing mortality among patients receiving open repair. We postulate increasing patient complexity and possibly decreased institutional memory (factors related to surgeon, anesthesia, and intensive care unit experience) in the era of increasing endovascular and diminishing open repairs.Fig 2Mortality rate for intact abdominal aortic aneurysms (AAAs) by procedure type and overall combined mortality.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Predicting Mortality of Ruptured Abdominal Aortic Aneurysms in the Era of Endovascular Repair

Previous risk prediction models of mortality after ruptured abdominal aortic aneurysm (rAAA) repair have been limited by imprecision, complexity, or inclusion of variables not available in the preoperative setting. Most importantly, these prediction models have been derived and validated before the adoption of endovascular aneurysm repair (EVAR) as a treatment for rAAA. We sought to derive and validate a new risk-prediction tool using only easily obtainable preoperative variables in patients with rAAA who are being considered for repair in the endovascular era. We used the Vascular Study Group of New England (VSGNE) database to identify all patients who underwent repair of RAAA (2006-2015). Variables were entered into a multivariable logistic regression model to identify independent predictors of 30-day mortality. Linear regression was then used to develop an equation to predict risk of 30-day mortality. During the study period, 649 patients underwent repair of rAAA; of these, 247 (38.1%) underwent EVAR and 402 (61.9%) underwent an open repair. The overall mortality associated with rAAA was 30.7% (open, 33.4% and EVAR, 26.2%). On multivariate modeling, the primary determinants of 30-day mortality were advanced age (>76 vs. ≤76years, odds ratio [OR]=2.91 and CI: 2.0-4.24), elevated creatinine (>1.5mg/dL vs. ≤1.5mg/dL, OR=1.57 and CI: 1.05-2.34), and lowest systolic blood pressure (SBP) (BP<70mm Hg vs. ≥70mm Hg, OR=2.65 and CI: 1.79-3.92). The logistic regression model had an area under a c-statistic of 0.69. The corresponding linear model used to provide a point estimate of 30-day mortality (%) was % mortality = 14 + 22 * (age >76) + 9 * (creatinine >1.5) + 20 * (bp <70) Using this model, patients can be stratified into different groups, each with a specific estimated risk of 30-day mortality ranging from a low of 14% to a high of 65%. In the endovascular era where both open and endovascular treatment are offered for the treatment of rAAA three variables, easily obtained in an emergency setting, accurately predict 30-day mortality for patients operated on for rAAA. This simple risk prediction tool could be used as a point of care decision aid to help the clinician in counseling patients and their families on treatment of those presenting with rAAA.

Vascular surgery, quo vadis?

Vascular surgery, currently a mono-specialty in a large number of countries, is dedicated to the diagnosis and management of all aspects of vascular disease (arterial, venous, and lymphatic), excluding the heart and brain vessels. Vascular diagnosis is complemented by non-invasive tests that are frequently performed by the managing physician, regardless of the intention for interventional treatment. Non-invasive tests, originally limited mainly to vascular ultrasound but now expanded to include computed tomography and magnetic resonance angiography, have largely reduced the need for arteriography and its attendant risks, preserving its diagnostic ability, and even improving preoperative planning and patient selection. The dawn of the new millenium found Vascular Surgery strengthened by the FDA approval of endografts for endovascular aneurysm repair (EVAR), a minimally invasive treatment that proved to be a revolution for the treatment of abdominal aortic aneurysms (AAA). It was clear at that point that a decade of research was successfully translated into clinical practice; however, the adoption of EVAR was really supported by trial evidence that became available the following years (1). Stretching the anatomical indications of EVAR and the need for endless follow-up has been a real challenge, partially addressed by new types of endografts. Around the same time, endoluminal vein ablation (ELVA) of the saphenous veins was also approved. Being further refined as new minimally invasive technology is invented, ELVA has replaced a large number of stripping procedures worldwide. Other areas where endovascular techniques have expanded our treatment armamentarium include the peripheral arteries, in order to prevent limb loss, deterioration of quality of life or death. Drug eluting stents and balloons, covered stents and improved atherectomy devices have been introduced into clinical practice. An area of active debate is the optimum management of extracranial carotid artery stenosis, where endarterectomy is still considered the standard of care, but judicious use of angioplasty and stenting (CAS) might improve outcomes in symptomatic patients. The availability of modern medical treatment has challenged the need for intervention in most patients with asymptomatic carotid artery stenosis and randomized controlled trials (CREST-2) are underway. Selective use of intervention in high-risk groups at a low peri-procedural risk and with sufficient life expectancy is required (2, 3). Vascular surgeons are actively involved in all kinds of trauma involving the blood vessels and also when these are thrombosed, including deep-vein thrombosis. The advent of new oral anticoagulants is expected to simplify the management of venous thromboembolism (4), but the post-thrombotic syndrome (PTS) is expected to be a burden for affected patients, unless pre-emptive thrombus removal becomes popular (5). Finally, vascular access for hemodialysis has been improved with efforts toward preferential construction of native arteriovenous fistulas and increased longevity of maintenance procedures performed for access complications being fruitful; however, there is an unmet need for further improvements, necessary for this challenging patient population. The present Specialty Grand Challenge article officially launches the Vascular Surgery Section of Frontiers in Surgery. The goal is to provide a unique open access forum for publication and rapid dissemination of important research covering the entire spectrum of Vascular Surgery.

Does the wide application of endovascular AAA repair affect the results of open surgery?

Purpose: to examine the effect of the adoption of endovascular aneurysm repair (EVAR) on the outcome of open repair (OR). Methods: between May 1998 and December 2001, EVAR (Zenith) was performed in 117 patients, and OR was performed because of anatomic restrictions in 40 (group A), and because of young age in 11 patients (group B). Results: EVAR patients had higher ASA classifications (p < 0.0001). EVAR was associated with a 98.3% (115 patients) technical success rate, one conversion to OR and one fatal cardiac arrest. Thirty-day mortality was 2.6% (3 patients) in EVAR, 15% (6 patients) in group A and none in group B. There was no difference in late survival between the three groups. Late reinterventions, mainly endovascular, were more frequent in EVAR. At a median follow-up of 17 months one stent-graft had migrated 5 mm distally and five stents had fractured, but without clinical consequence. Conclusions: EVAR provides good results even with inclusion of high-risk patients. The adoption of EVAR may adversely affect the results of OR offered to patients because of anatomic considerations. However, OR continues to be the first option for low-risk young patients.Eur J Vasc Endovasc Surg 26, 188-194 (2003)