Two Decades of Endovascular Abdominal Aortic Aneurysm Repair: Enormous Progress With Serious Lessons Learned

T he modern open surgical management of abdominal aortic aneurysm (AAA) has changed little since its inception in the 1950s. Endoaneurysmorrhaphy, first described by Rudolph Matas in 1888, involved ligating the branches of an aneurysm from within the aneurysm sac. Approximately 25 years later at the beginning of the 20th century, Alexis Carrel received the Nobel Prize for demonstrating the feasibility of suture repair of arteries and perfecting an anastomotic technique to join 2 vessels. With these techniques established, an AAA could be repaired by anastomosis of a synthetic conduit to the aorta just proximal and distal to the AAA, thereby preserving antegrade blood flow.1 Dubost was the first to marry these 2 techniques in 1952, with the first report of a successful open AAA repair with homograft replacement.2 Aside from the development of various different types of conduit materials, open AAA repair has remained largely unchanged through to the present day. The most dramatic shift in the surgical management of AAA occurred in 1991, when Juan Parodi reported the first endovascular AAA repair (EVAR).3 This transformative moment marks the beginning of minimally invasive AAA repair as an alternative to open surgical repair. Whereas the elective management of AAA traditionally had depended solely on open surgical repair,4,5 these recent developments in catheter-based, endovascular techniques led to a substantial increase in the proportion of AAAs managed electively with EVAR. In 2006, only 15 years after the initial EVAR report, 21 725 EVAR procedures were performed in the United States, exceeding for the first time the number of open surgical AAA repairs.6 Currently, >70% of elective AAA repairs in the United States are performed with EVAR.6 Although the goals of EVAR and open surgical AAA repair are identical (ie, to eliminate the risk of death from rupture of AAA),