Since its inception in the early 1990s, endovascular repair (EVR) of aneurysms has been subjected to analysis in several randomised ontrolled trials. Now it is a mainstay of treatment for abdominal aortic aneurysms (AAA). As the technique has moved from conception through competitive analysis and finally into mainstream practice, several issues have remained controversial. These will be addressed in this brief review.

Endovascular or Open Repair for Abdominal Aortic Aneurysms
Despite a wealth of comparative evidence,^1,2 there is still fierce debate as to whether EVR should be positioned as the first-line therapy for AAA. his may be illustrated by the take-up rates for EVR across individual countries in Europe, with the percentage of patients treated by endovascular therapy ranging from the high teens to just under 50%. At present, approximately 70–80% of patients with an infra-renal AAA may be suitable for an EVR using morphological indications unrestricted by the device manufacturers’ indications for use. Without any doubt, those treating AAA should be able to assess patients for both open and endovascular therapies and offer both. It is the author’s belief, however, that there are now compelling data to suggest that mostaneurysms should be considered for an endovascular first approach. All of the randomised trials published to date have suggested that EVR offers an early mortality advantage of approximately 4% – an advantage that is maintained (for aneurysm-related mortality) in the mid-term.³ Similarly, robust administrative data sets from the US4 and the UK have demonstrated that EVR has a significantly lower overall mortality than open repair for elective aneurysm surgery in all age groups (1.2 versus 4.8%). The difference in mortality is particularly important in older patients (respective mortality in patients >85 years of age: 2.7 versus 11.2%). Perhaps as importantly, the percentage of patients over 80 years of age discharged home following EVR is 10% higher than those undergoing open repair (90 versus 80%, Holt and Thompson, unpublished data).

These early mortality data are reflected in patient preference for operative technique. Winterborne et al.⁵ surveyed 100 patients with small aneurysms and reported that 84% of patients preferred endovascular over open repair. The most important factors defining this choice were post-operative mortality and morbidity. The cost-effectiveness of EVR has recently been the subject of a Health Technology Appraisal by the National Institute for Health and Clinical Excellence (NICE) in the UK. In general terms, the likelihood of a technology being recommended for adoption is related to the incremental cost-effectiveness ratio (ICER). An ICER between £20,000 and £30,000 is often considered an appropriate threshold. Using estimates of cost differential, aneurysm-related mortality, all-cause mortality and late re-intervention rates, NICE suggested a possible ICER for EVR of £12,000. NICE recommended EVR as an appropriate treatment option for AAA and suggested that “the decisions on whether endovascular aneurysm repair is preferred over open surgical repair should be made jointly by the patient and their clinician after assessment of a number of factors, including: aneurysm size and morphology; patient age, life expectancy and fitness for open surgery;the short- and long-term benefits and risks of the procedures including aneurysm-related mortality and operative mortality.”