Abdominal aortic aneurysm: while there is still no cure, the key question is which patients to select for intervention and which intervention to select!

Abstract

Abdominal aortic aneurysm: while there is still no cure, the key question is which patients to select for intervention and which intervention to select! In 1952, Dubost et al. 1 began the era of effective repair of aneurysms of the infrarenal aorta using homologous cadaveric aorta grafts, after aneurysmectomy. Development of arterial substitutes, more rigorous surgical techniques, better understanding of the disease, and the advent of ultrasonography which increased diagnoses and perfected preoperative, intraoperative (anesthesia) and postoperative clinical control, surgery for infrarenal aneurysms came to be routine and results became ever more encouraging. The prospect of effective treatment began to raise doubts with relation to which patients with asymptomatic aneurysms were suitable candidates for treatment. An understanding of the natural history of the disease became indispensable and many studies were conducted to investigate this subject.As the number of patients operated increased, it became clear that, although mortality rates linked to elective conventional surgery exhibited a reduction over the years (17.4% to 5.0% in 20 years, 2 between 2.5% and 3.5% in Brazil), 3-5 mortality from ruptured aneurysms remained elevated (over 50%). 6 This finding led to an aggressive approach to treatment of aneurysms, with surgery prescribed even for low risk patients, the elderly and patients with aneurysms considered to be small. 7,8 While this approach does eliminate the possibility of rupture in these patients, a considerable contingent of individuals, with small aneurysms, would be subjected to major surgical operations, which are never risk free and may be unnecessary, since many aneurysms remain stable 9,10 and 75% of people who have aneurysms die of other diseases, 11 in particular cardiovascular conditions.It therefore became imperative to establish which patients are at greater risk of aneurysm rupture, in other words, which factors influence rupture of infrarenal aortic aneurysms.Estes 12 reported in 1952 that the primary cause of death among patients with abdominal aneurysms was rupture and, in second place, coronary disease. In 1962, Shatz et al. 13 recorded a reduction in the number of ruptures, associated with the spread of surgical treatment of aneurysms. These authors considered aneurysms with a maximum transverse diameter of up to 7.5 cm to be small. These observations were corroborated by Szilagui et al. in 1966, 14 who claimed that surgical repair of aneurysms resulted in equal survival to that observed in the normal population and recommended surgical treatment when the maximum aneurysm diameter reached 6.0 cm. Hollier et al. 15 demonstrated that coronary disease limited survival of patients after aneurysm repair.Currently, there is consensus that the single most important risk factor for rupture of an abdominal aortic aneurysm (AAA) is its maximum transverse diameter and this is therefore the factor that is most often used when prescribing surgery. Analysis of several different studies showed...

Results of Open and Endovascular Abdominal Aortic Aneurysm Repair According to the E-PASS Score

“…The economical aspect should also be considered because of the higher costs associated with EVAR. Another hindrance could be the pre-acquired concepts on modern surgical techniques that patients bring from the electronic media, which generates a layperson preference [ 1 , 40 , 41 ] , and also the manner both techniques are offered to patients by the attending physician [ 42 ] .…”

“…Recently, Silva [ 1 ] published an editorial reflecting on the cost/benefit and technical aspects in order to choose the best option between open (OR) and endovascular (EVAR) procedures in the repair of abdominal aortic aneurysms (AAA). Case series and randomized clinical trials comparing the results between OR and EVAR demonstrate that there is a reduction in the 30-day mortality associated with the less invasive technique [ 2 - 6 ] .…”