Endovascular repair of abdominal aortic aneurysm: no cause for alarm.

In the now 20 years since it was initially described, endovascular repair of abdominal aortic aneurysm (EVAR) has matured to the point where some 70% to 80% of potentially eligible patients are treated with this modality.1 Furthermore, the majority of patients managed with conventional open operation are those in whom anatomic considerations disallow EVAR. In the current issue of Circulation, Schanzer et al2 detail anatomic characteristics of a large patient cohort treated with EVAR, indicating that the primary study end point of abdominal aortic aneurysm (AAA) sac enlargement may be alarmingly high (40% at 3 years); such sac enlargement is considered a surrogate in their report for threat of late AAA rupture, representing, of course, EVAR treatment failure. Although the implications of this study referable to appropriate patient (anatomic) selection for, and close follow-up after EVAR are both evident and emphasized elsewhere,3 the authors’ concerns relative to late performance of EVAR are, at this point in the evolution of this technology, refuted by a substantial body of literature. To wit, in consideration of the clinically relevant outcomes of late AAA rupture and/or freedom from AAA-related mortality, EVAR has perhaps exceeded the expectations of even its more aggressive proponents. A surfeit of literature encompassing single-center cohort studies, registries/trials, and even randomized trials of EVAR versus open repair for AAA has verified the clinical effectiveness of EVAR. In the 7000 EVAR-treated patients represented in these studies1,4–7 reflecting the above-noted different study designs, freedom from AAA-related mortality averages a minimum of 95% even out to 5 years with actuarial methods. A large longitudinal study of EVAR in Medicare beneficiaries (with a time interval identical to that in the Schantzer study) found late AAA rupture after EVAR to be a rare event (1.8% at 4 years).8 These data, combined with the Level 1 evidence verifying the perioperative advantages of EVAR, doubtlessly account for the rapid dissemination of EVAR and its enthusiastic adoption by both patients and vascular surgeons.6,9 How, then, are the data of Schantzer et al reconciled with the preponderance of favorable literature referable to late performance of EVAR? Article see p 2848