From the neck to the heel.

The less invasive endovascular aneurysm repair (EVAR) is regarded as a less effective procedure for the treatment of abdominal aortic aneurysm (AAA) since it is associated with frequent re-interventions and failures in the midterm mainly related to aneurysm neck problems. Open surgical conversion is often required after EVAR failure. Open repair of AAA is associated with fewer aortic-related re-interventions and remains the gold standard. However, about one-third of open surgery survivors have been reported to undergo at least one vascular intervention after 15 years.1 Failure may lie in unrecognised disease or vulnerable aorta with recurrent aneurysmal development especially at the neck, which is the ‘Achilles heel’ of any aortic repair. In this perspective, open repair may postpone the time of aortic failure when compared with EVAR, but the aorta remains at risk to fail. The perceptionof durability attributed to open repairmay be due to the lack of standardised imaging follow-up after surgery. In this article of EJVES, data from a randomised trial comparing EVAR with open repair for AAA treatment clearly showed that as, in the EVAR era, the implementation of rigorous imaging follow-up after aortic repair has led to the perception that also open aneurysm surgery may not be a definite therapy for AAA.2 de Bruin et al. re-measured the length of the residual infrarenal aortic neck after repair in 156 aneurysms treated with open surgery and 160 assigned to EVAR in the Dutch Randomized Endovascular Aneurysm Management (DREAM) trial. The distance from the caudal artery to the proximal graft anastomosis was significantly shorter in the EVAR group ranging from 0 to 6mm, while the average infrarenal neck length in the open repair group was 24 mm (ranging from 16 to 30 mm). The shorterneck lengthafterEVARwasunderstandably related todevice instructions for use and required to ensure adequate sealing for a nonsutured prosthesis. Nevertheless, the almost 2.5 cm of remaining neck after open surgery might be a reason for concern, also because this persisting neck was not intentionally achieved by most surgeons. The DREAM authors indeed specifically queried surgeons about theneck length they left after surgeryand found that only 6% were accurate in this respect with many surgeons (54%), indicating the proximal anastomosis within 10 mm of the caudal