Management of Aortic Aneurysms: Is Surgery of Historic Interest Only?

Abstract

Since its advent in 1991, endovascular aortic aneurysm repair (EVAR) has become a mainstay of treatment for abdominal aortic aneurysms (AAA). Studies such as the comparison of endovascular aneurysm repair with open repair in patients with abdominal aortic aneurysm (EVAR 1) trial, have demonstrated the effectiveness of EVAR in reducing perioperative mortality. Technological improvements in graft design and delivery account for an increasing utilization of endovascular repair. Newer branch and fenestrated graft designs have allowed for treatment of patients with complex aortic anatomy that previously could not be treated with EVAR. Endovascular repair, while dominant, is unlikely to eliminate the need for open repair or to relegate open surgery for AAA to historical interest only. The unprecedented adoption of EVAR has led to complications and modes of failure that were not seen with open repair. The rate of failure is markedly increased when endografts are used outside of the instructions for use (IFU). The long-term durability of fenestrated and investigational branch devices remains to be established. The demand for an endovascular approach by patients and the willingness of physicians to place endografts outside the anatomic IFU criteria may have resulted in the pendulum swinging too far away from open surgical management. The consequence of reduced open aortic surgeries is a concern for both patient care as well as training for vascular surgery fellows. Vascular surgery training programs will require innovative changes in training to assure that vascular surgery trainees will have the requisite skill and experience required to competently perform open surgical repair on what will undoubtedly be some of the most complex aortic pathology.

Endovascular Abdominal Aortic Aneurysm Repair With Ovation Alto Stent Graft: Protocol for the ALTAIR (ALTo endogrAft Italian Registry) Study

“…The traditional approach is represented by the open surgical repair [ 3 , 4 ]. As an alternative, the less invasive endovascular treatment has been proposed (endovascular aneurysm repair [EVAR]), which has become the first treatment of choice in patients with suitable anatomy [ 5 , 6 ]. EVAR represents a minimally invasive technique that has overcome some critical issues of open surgical repair such as higher intraoperative and perioperative risk; the necessity of general anesthesia; intensive care unit stay; and higher cardiac, pulmonary, and renal complications [ 7 ].…”

The Polymer-Based Technology in the Endovascular Treatment of Abdominal Aortic Aneurysms

“…[5,6] In addition to this approach, a less invasive endovascular treatment has been proposed. Over the years, endovascular aneurysm repair (EVAR) has become the first treatment of choice in patients with suitable anatomy [7][8][9]. EVAR represents a minimally invasive technique that has overcome some critical issues of open surgical repair such as higher intra-and peri-operative risk, the necessity of general anesthesia, intensive Care Unit stay, higher cardiac, pulmonary and renal complications.…”

In Vivo Evaluation of Customized Aortic Repair Using a Novel Survival Model

“…6e8 Moreover, tortuous or severely angulated aortic anatomy, insufficient proximal neck length, and large neck diameter remain outside the EVAR anatomic instructions for use criteria. 9,10 To overcome the limitations of conventional open surgery and EVAR, alternative minimally invasive approaches have been developed for the treatment of AAA by filling the aneurysm sac. Since the beginning of this century, reports have emerged describing aneurysm exclusion by direct or indirect aneurysm sac instillation of in situ curing polymers based on acrylates, alginates, or glucosamine.…”