Endovascular treatment of aortic aneurysms: State of the art

Article

Opinion statement

Abdominal aortic aneurysms (AAAs) continue to be a leading cause of death, with increasing incidence and prevalence. Endovascular aneurysm repair (EVAR) now represents the most common method of AAA repair in the United States. Ongoing improvements in endovascular stent-graft technology have occurred since the first published report of EVAR in 1991. These improvements have led to multiple US Food and Drug Administration-approved devices, streamlined operative techniques, and extended applicability of EVAR. Despite these facts, basic anatomic considerations still eliminate many patients from being offered EVAR. Distinct advantages of EVAR over open repair have been demonstrated, including a less invasive operative exposure, decreased transfusion requirements, shortened intensive care unit and hospital stay, and decreased perioperative mortality. It is our opinion that in 2009, anatomically suitable patients should be offered EVAR as first-line therapy, except for the less common scenario of the young and fit patient, for which open repair should be strongly considered. Use of EVAR for ruptured AAAs also has shown promise, yielding survival results commensurate with the best single-center results with open repair for rupture. However, questions remain regarding the long-term efficacy of EVAR in preventing aneurysm-related death for all patients treated with this technique. As device improvements and technical advances continue, it is reasonable to expect that long-term results will improve as well. Furthermore, the advent of fenestrated and multi-branch endograft technology is expanding indications, and will continue to enlarge the percentage of patients who will be considered acceptable candidates for EVAR. Lastly, randomized clinical trials are under way to determine whether the generally accepted threshold of 5.5 cm for elective open AAA repair should be decreased in patients who are candidates for EVAR. Until further data emerge, standard guidelines for elective aneurysm repair should remain the norm.

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References and Recommended Reading

  1. 1.
    Johnston KW, Rutherford RB, Tilson MD, et al.: Suggested standards for reporting on arterial aneurysms. Subcommittee on Reporting Standards for Arterial Aneurysms, Ad Hoc Committee on Reporting Standards, Society for Vascular Surgery and North American Chapter, International Society for Cardiovascular Surgery. J Vasc Surg 1991, 13:452–458.PubMedCrossRefGoogle Scholar
  2. 2.
    Dimick JB, Upchurch GR Jr: Endovascular technology, hospital volume, and mortality with abdominal aortic aneurysm surgery. J Vasc Surg 2008, 47:1150–1154.PubMedCrossRefGoogle Scholar
  3. 3.
    Mealy K, Salman A: The true incidence of ruptured abdominal aortic aneurysms. Eur J Vasc Surg 1988, 2:405–408.PubMedCrossRefGoogle Scholar
  4. 4.
    Eliason JL, Wainess RM, Dimick JB, et al.: The effect of secondary operations on mortality following abdominal aortic aneurysm repair in the United States: 1988–2001. Vasc Endovasc Surg 2005, 39:465–472.CrossRefGoogle Scholar
  5. 5.
    Lederle FA, Johnson GR, Wilson SE, et al.: Rupture rate of large abdominal aortic aneurysms in patients refusing or unfit for elective repair. JAMA 2002, 287:2968–2972.PubMedCrossRefGoogle Scholar
  6. 6.
    Lederle FA, Wilson SE, Johnson GR, et al.: Immediate repair compared with surveillance of small abdominal aortic aneurysms. N Engl J Med 2002, 346:1437–1444.PubMedCrossRefGoogle Scholar
  7. 7.
    United Kingdom Small Aneurysm Trial Participants: Long-term outcomes of immediate repair compared with surveillance of small abdominal aortic aneurysms. N Engl J Med 2002, 346:1445–1452.CrossRefGoogle Scholar
  8. 8.
    Mortality results for randomised controlled trial of early elective surgery or ultrasonographic surveillance for small abdominal aortic aneurysms. The UK Small Aneurysm Trial Participants. Lancet 1998, 352:1649–1655.Google Scholar
  9. 9.
    Parodi JC, Palmaz JC, Barone HD: Transfemoral intraluminal graft implantation for abdominal aortic aneurysms. Ann Vasc Surg 1991, 5:491–499.PubMedCrossRefGoogle Scholar
  10. 10.
    Greenberg RK, Deaton D, Sullivan T, et al.: Variable sac behavior after endovascular repair of abdominal aortic aneurysm: analysis of core laboratory data. J Vasc Surg 2004, 39:95–101.PubMedCrossRefGoogle Scholar
  11. 11.
    Prinssen M, Verhoeven EL, Buth J, et al.: A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms. N Engl J Med 2004, 351:1607–1618.PubMedCrossRefGoogle Scholar
  12. 12.
    Blankensteijn JD, de Jong SE, Prinssen M, et al.: Two-year outcomes after conventional or endovascular repair of abdominal aortic aneurysms. N Engl J Med 2005, 352:2398–2405.PubMedCrossRefGoogle Scholar
  13. 13.
    EVAR trial participants: Endovascular aneurysm repair versus open repair in patients with abdominal aortic aneurysm (EVAR trial 1): randomised controlled trial. Lancet 2005, 365:2179–2186.CrossRefGoogle Scholar
  14. 14.
    Greenhalgh RM, Brown LC, Kwong GP, et al.: Comparison of endovascular aneurysm repair with open repair in patients with abdominal aortic aneurysm (EVAR trial 1), 30-day operative mortality results: randomised controlled trial. Lancet 2004, 364:843–848.PubMedCrossRefGoogle Scholar
  15. 15.
    Schermerhorn ML, O’Malley AJ, Jhaveri A, et al.: Endovascular vs. open repair of abdominal aortic aneurysms in the Medicare population. N Engl J Med 2008, 358:464–474.PubMedCrossRefGoogle Scholar
  16. 16.
    van Marrewijk CJ, Leurs LJ, Vallabhaneni SR, et al.: Risk-adjusted outcome analysis of endovascular abdominal aortic aneurysm repair in a large population: how do stentgrafts compare? J Endovasc Ther 2005, 12:417–429.PubMedCrossRefGoogle Scholar
  17. 17.
    Hobo R, Buth J: Secondary interventions following endovascular abdominal aortic aneurysm repair using current endografts. A EUROSTAR report. J Vasc Surg 2006, 43:896–902.PubMedCrossRefGoogle Scholar
  18. 18.
    Fotis T, Tsoumakidou G, Katostaras T, et al.: Cost and effectiveness comparison of endovascular aneurysm repair versus open surgical repair of abdominal aortic aneurysm: a single-center experience. J Vasc Nurs 2008, 26:15–21.PubMedCrossRefGoogle Scholar
  19. 19.
    Feezor RJ, Huber TS, Berceli SA, et al.: Impact of endograft design and product line on the device cost of endovascular aneurysm repair. J Vasc Surg 2008, 47:499–503.PubMedCrossRefGoogle Scholar
  20. 20.
    Rosenberg BL, Comstock MC, Butz DA, et al.: Endovascular abdominal aortic aneurysm repair is more profitable than open repair based on contribution margin per day. Surgery 2005, 137:285–292.PubMedCrossRefGoogle Scholar
  21. 21.
    Epstein DM, Sculpher MJ, Manca A, et al.: Modelling the long-term cost-effectiveness of endovascular or open repair for abdominal aortic aneurysm. Br J Surg 2008, 95:183–190.PubMedCrossRefGoogle Scholar
  22. 22.
    Hayter CL, Bradshaw SR, Allen RJ, et al.: Follow-up costs increase the cost disparity between endovascular and open abdominal aortic aneurysm repair. J Vasc Surg 2005, 42:912–918.PubMedCrossRefGoogle Scholar
  23. 23.
    Veith FJ, Ohki T, Lipsitz EC, et al.: Treatment of ruptured abdominal aneurysms with stent grafts: a new gold standard? Semin Vasc Surg 2003, 16:171–175.PubMedCrossRefGoogle Scholar
  24. 24.
    Hinchliffe RJ, Yusuf SW, Macierewicz JA, et al.: Endovascular repair of ruptured abdominal aortic aneurysm-a challenge to open repair? Results of a single centre experience in 20 patients. Eur J Vasc Endovasc Surg 2001, 22:528–534.PubMedCrossRefGoogle Scholar
  25. 25.
    Yusuf SW, Whitaker SC, Chuter TA, et al.: Emergency endovascular repair of leaking aortic aneurysm. Lancet 1994, 344:1645.PubMedCrossRefGoogle Scholar
  26. 26.
    Alsac JM, Desgranges P, Kobeiter H, Becquemin JP: Emergency endovascular repair for ruptured abdominal aortic aneurysms: feasibility and comparison of early results with conventional open repair. Eur J Vasc Endovasc Surg 2005, 30:632–639.PubMedCrossRefGoogle Scholar
  27. 27.
    Hechelhammer L, Lachat ML, Wildermuth S, et al.: Midterm outcome of endovascular repair of ruptured abdominal aortic aneurysms. J Vasc Surg 2005, 41:752–757.PubMedCrossRefGoogle Scholar
  28. 28.
    Lagana D, Carrafiello G, Mangini M, et al.: Emergency endovascular treatment of abdominal aortic aneurysms: feasibility and results. Cardiovasc Intervent Radiol 2006, 29:241–248.PubMedCrossRefGoogle Scholar
  29. 29.
    Mehta M, Taggert J, Darling RC 3rd, et al.: Establishing a protocol for endovascular treatment of ruptured abdominal aortic aneurysms: outcomes of a prospective analysis. J Vasc Surg 2006, 44:1–8.PubMedCrossRefGoogle Scholar
  30. 30.
    Brandt M, Walluscheck KP, Jahnke T, et al.: Endovascular repair of ruptured abdominal aortic aneurysm: feasibility and impact on early outcome. J Vasc Interv Radiol 2005, 16:1309–1312.PubMedGoogle Scholar
  31. 31.
    Moore R, Nutley M, Cina CS, et al.: Improved survival after introduction of an emergency endovascular therapy protocol for ruptured abdominal aortic aneurysms. J Vasc Surg 2007, 45:443–450.PubMedCrossRefGoogle Scholar
  32. 32.
    Leon LR Jr, Labropoulos N, Laredo J, et al.: To what extent has endovascular aneurysm repair influenced abdominal aortic aneurysm management in the state of Illinois? J Vasc Surg 2005, 41:568–574.PubMedCrossRefGoogle Scholar
  33. 33.
    Hinchliffe RJ, Bruijstens L, MacSweeney ST, Braithwaite BD: A randomised trial of endovascular and open surgery for ruptured abdominal aortic aneurysm—results of a pilot study and lessons learned for future studies. Eur J Vasc Endovasc Surg 2006, 32:506–513; discussion 14–5.PubMedCrossRefGoogle Scholar
  34. 34.
    Harkin DW, Dillon M, Blair PH, et al.: Endovascular ruptured abdominal aortic aneurysm repair (EVRAR): a systematic review. Eur J Vasc Endovasc Surg 2007, 34:673–681.PubMedCrossRefGoogle Scholar
  35. 35.
    Hartung O, Vidal V, Marani I, et al.: Treatment of an early type II endoleak causing hemorrhage after endovascular aneurysm repair for ruptured abdominal aortic aneurysm. J Vasc Surg 2007, 45:1062–1065.PubMedCrossRefGoogle Scholar
  36. 36.
    Coppi G, Silingardi R, Gennai S, et al.: A single-center experience in open and endovascular treatment of hemodynamically unstable and stable patients with ruptured abdominal aortic aneurysms. J Vasc Surg 2006, 44:1140–1147.PubMedCrossRefGoogle Scholar
  37. 37.
    Kapma MR, Verhoeven EL, Tielliu IF, et al.: Endovascular treatment of acute abdominal aortic aneurysm with a bifurcated stentgraft. Eur J Vasc Endovasc Surg 2005, 29:510–515.PubMedCrossRefGoogle Scholar
  38. 38.
    Scharrer-Pamler R, Kotsis T, Kapfer X, et al.: Endovascular stent-graft repair of ruptured aortic aneurysms. J Endovasc Ther 2003, 10:447–452.PubMedCrossRefGoogle Scholar
  39. 39.
    Larzon T, Lindgren R, Norgren L: Endovascular treatment of ruptured abdominal aortic aneurysms: a shift of the paradigm? J Endovasc Ther 2005, 12:548–555.PubMedCrossRefGoogle Scholar
  40. 40.
    Van Herzeele I, Vermassen F, Durieux C, et al.: Endovascular repair of aortic rupture. Eur J Vasc Endovasc Surg 2003, 26:311–316.PubMedCrossRefGoogle Scholar
  41. 41.
    Kapma MR, Groen H, Oranen BI, et al.: Emergency abdominal aortic aneurysm repair with a preferential endovascular strategy: mortality and cost-effectiveness analysis. J Endovasc Ther 2007, 14:777–784.PubMedCrossRefGoogle Scholar
  42. 42.
    Hirsch AT, Haskal ZJ, Hertzer NR, et al.: ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. Circulation 2006, 113:e463–e654.PubMedCrossRefGoogle Scholar
  43. 43.
    Brewster DC, Cronenwett JL, Hallett JW Jr, et al.: Guidelines for the treatment of abdominal aortic aneurysms. Report of a subcommittee of the Joint Council of the American Association for Vascular Surgery and Society for Vascular Surgery. J Vasc Surg 2003, 37:1106–1117.PubMedCrossRefGoogle Scholar
  44. 44.
    Peppelenbosch N, Buth J, Harris PL, et al.: Diameter of abdominal aortic aneurysm and outcome of endovascular aneurysm repair: does size matter? A report from EUROSTAR. J Vasc Surg 2004, 39:288–297.PubMedCrossRefGoogle Scholar
  45. 45.
    Browne TF, Hartley D, Purchas S, et al.: A fenestrated covered suprarenal aortic stent. Eur J Vasc Endovasc Surg 1999, 18:445–449.PubMedCrossRefGoogle Scholar
  46. 46.
    Greenberg RK, Haulon S, Lyden SP, et al.: Endovascular management of juxtarenal aneurysms with fenestrated endovascular grafting. J Vasc Surg 2004, 39:279–287.PubMedCrossRefGoogle Scholar
  47. 47.
    Verhoeven EL, Muhs BE, Zeebregts CJ, et al.: Fenestrated and branched stent-grafting after previous surgery provides a good alternative to open redo surgery. Eur J Vasc Endovasc Surg 2007, 33:84–90.CrossRefGoogle Scholar
  48. 48.
    Scurr JR, Brennan JA, Gilling-Smith GL, et al.: Fenestrated endovascular repair for juxtarenal aortic aneurysm. Br J Surg 2008, 95:326–332.PubMedCrossRefGoogle Scholar
  49. 49.
    Mehta M, Veith FJ, Ohki T, et al.: Unilateral and bilateral hypogastric artery interruption during aortoiliac aneurysm repair in 154 patients: a relatively innocuous procedure. J Vasc Surg 2001, 33:S27–S32.PubMedCrossRefGoogle Scholar
  50. 50.
    Lin PH, Bush RL, Chaikof EL, et al.: A prospective evaluation of hypogastric artery embolization in endovascular aortoiliac aneurysm repair. J Vasc Surg 2002, 36:500–506.PubMedCrossRefGoogle Scholar
  51. 51.
    Kritpracha B, Comerota AJ: Unilateral lower extremity paralysis after coil embolization of an internal iliac artery aneurysm. J Vasc Surg 2004, 40:819–821.PubMedCrossRefGoogle Scholar
  52. 52.
    Geraghty PJ, Sanchez LA, Rubin BG, et al.: Overt ischemic colitis after endovascular repair of aortoiliac aneurysms. J Vasc Surg 2004, 40:413–418.PubMedCrossRefGoogle Scholar
  53. 53.
    Haulon S, Greenberg RK, Pfaff K, et al.: Branched grafting for aortoiliac aneurysms. Eur J Vasc Endovasc Surg 2007, 33:567–574.PubMedCrossRefGoogle Scholar
  54. 54.
    Dowdall JF, Greenberg RK, West K, et al.: Separation of components in fenestrated and branched endovascular grafting-branch protection or a potentially new mode of failure? Eur J Vasc Endovasc Surg 2008, 36:2–9.PubMedCrossRefGoogle Scholar
  55. 55.
    Greenberg RK, Lu Q, Roselli EE, et al.: Contemporary analysis of descending thoracic and thoracoabdominal aneurysm repair: a comparison of endovascular and open techniques. Circulation 2008, 118:808–817.PubMedCrossRefGoogle Scholar
  56. 56.
    Muhs BE, Verhoeven EL, Zeebregts CJ, et al.: Mid-term results of endovascular aneurysm repair with branched and fenestrated endografts. J Vasc Surg 2006, 44:9–15.PubMedCrossRefGoogle Scholar

Copyright information

© Current Medicine Group, LLC 2009

Authors and Affiliations

  1. 1.Section of Vascular SurgeryUniversity of Michigan Health System, Cardiovascular Center 5372Ann ArborUSA

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