Developments in Endovascular Abdominal Aortic Aneurysm Treatment

Since its inception in the early 1990s, endovascular repair (EVR) of aneurysms has been subjected to analysis in several randomised controlled 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. This 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 most aneurysms 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of age discharged home following EVR is 10% higher than those undergoing open repair (90 versus 80%, Holt and Thompson, unpublished data).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.