Re: ‘Long-term Outcomes and Sac Volume Shrinkage after Endovascular Popliteal Artery Aneurysm Repair (EVPAR)’

Abstract

We have become dependent on imaging to define the need for and timing of interventions after EVAR. Imaging, however, is not without limitations and patients at persistent risk of rupture may frequently be misidentified. Intermittent or position dependent type-I endoleaks are a good example of the situation where absence of endoleak on CTA may not be a perfect surrogate of success. 1 In another publication, it was found that effective sealing in heavily thrombotic necks is possible as neck remodelling results in thrombus dissolution and complete graft-wall apposition in the mid-term. This occurred without any additional risk of rupture. 2 However in the present study, the authors believe that thrombosis was not the reason why the primary endoleaks sealed spontaneously. The appropriate interpretation is different. Much has changed in the technology, planning and execution of EVAR since the consensus publication of 2002. 3 In the case of appropriate evaluation of neck suitability, correct sizing and implantation, and consequently optimal sealing of the proximal endograft, immediate type-Ia endoleaks are most likely transitory. A watchful waiting period may be preferable to an aggressive strategy directed at immediate repair. In contrast to what is suggested, the authors defend the position that an unnecessary obsession with intra-operative correction of the picture may well result in the loss of a life.