The objectives of this article from Sicard et al are two-fold. First, it is meant to assess the benefit of elective endovascular aneurysm repair (EVAR) in patients at high-risk for open surgery and second, compare the obtained outcomes with those of the EVAR 2 trial published in The Lancet in 2005.1EVAR trial participantsEndovascular aneurysm repair and outcome in patients unfit for open repair of abdominal aortic aneurysm (EVAR trial 2) randomised controlled trial.Lancet. 2005; 365: 187-192Abstract Full Text Full Text PDF PubMed Google Scholar The conclusions of the current article were substantially different from those of the EVAR 2 report. The authors have made a commendable effort to explain the differences, and understandably, they try to convince the reader that their conclusion is the correct one. What is the nature of the substantial differences in the main outcome events after EVAR in these two studies? The design of the current analysis is not straightforward. The baseline patient cohort came from five commercially sponsored nonrandomized investigational device exemption (IDE) studies, with inherently several unknown factors. The selection criteria to include a patient, although not specified, most likely varied between the different studies. Study protocols from device manufacturers have a natural tendency to avoid the selection of patients with an increased risk of postoperative complications, including death. Nevertheless, the authors were able to identify a group of patients at high operative risk. The factors determining high-risk patients were probably not equally balanced between the different studies, and most important, no formal meta-analysis methodology was used. Crude minimal criteria, requiring the presence of (only) one comorbidity, sufficed to define a patient as high risk, which contrasted from the severity of the requirements for patient enrolment in EVAR 2.2Brown L.C. Epstein D. Manca A. Beard J.D. Powell J.T. Greenhalgh R.M. The UK endovascular aneurysm repair (EVAR) trials; design, methodology and progress.Eur J Vasc Endovasc Surg. 2004; 27: 372-381Abstract Full Text Full Text PDF PubMed Scopus (119) Google Scholar The reader must be puzzled by finding out that a portion of these patients received open repair despite being considered unfit for open surgery. The details of why a patient was allocated to EVAR or open repair were not specified. From a design point of view, the EVAR 2 trial is far superior. Supported by an independent governmental grant and with proper randomization of a large patient group between treatments, EVAR 2 is supposed to provide level I scientific evidence. The details were less transparent, however, and the fact that to date no straightforward generally accepted criteria exist to define the patient unfit for open repair caused some confusing observations. In addition, some disturbing logistic problems occurred during the trial. Notably, the significant delay between randomization and treatment was at the expense of several ruptured aneurysms before the intervention. All weaknesses were detailed in the discussion of the present article. One of the other flaws in EVAR 2 was that a number of patients initially were misclassified, as these patients (crossing-over from watchful waiting to intervention) did tolerate a secondary AAA procedure well, including open repair in 12 patients. Where does this leave us? After careful studying the present article in this journal and the report in The Lancet, it occurs that there is more than one category of high-risk patients. Considering the substantial difference in all-cause mortality after 4 years of follow-up, the average patient in the IDE studies was not nearly as unfit as most of the patients in EVAR 2. One should note that in unfit patients, not only the all-cause mortality but also the aneurysm-related mortality (including the one-month rate) proportionally increases.3Buth J. Van Marrewijk C.J. Harris P.L. Hop W.C.J. Riambau V. Laheij R.J.F. EUROSTAR collaboratorsOutcome of endovascular abdominal aortic aneurysm repair in patients with conditions considered unfit for an open procedure. A report on the EUROSTAR experience.J Vasc Surg. 2002; 35: 211-221Abstract Full Text Full Text PDF PubMed Scopus (153) Google Scholar Perhaps the severest problem of EVAR 2 was that many patients were too sick for even an endovascular procedure. What can we learn from these two articles? For intermediately increased-risk patients, who represent large proportion in the average vascular surgical practice, the conclusions of the IDE derived data that EVAR may be the best treatment can be accepted. In patients with a very short life expectancy, for instance <1 year,3Buth J. Van Marrewijk C.J. Harris P.L. Hop W.C.J. Riambau V. Laheij R.J.F. EUROSTAR collaboratorsOutcome of endovascular abdominal aortic aneurysm repair in patients with conditions considered unfit for an open procedure. A report on the EUROSTAR experience.J Vasc Surg. 2002; 35: 211-221Abstract Full Text Full Text PDF PubMed Scopus (153) Google Scholar a policy of nonintervention, as suggested by the EVAR 2 reporters, definitely is the wiser option.