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Gilmore BF, Scali ST, D’Oria M, Neal D, Schermerhorn ML, Huber TS, Columbo JA, Stone DH. Temporal Trends and Outcomes of Abdominal Aortic Aneurysm Care in the United States. Circ Cardiovasc Qual Outcomes 2024; 17:e010374. [PMID: 38775052 PMCID: PMC11187661 DOI: 10.1161/circoutcomes.123.010374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 04/08/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND Endovascular aortic aneurysm repair (EVAR) has had a dynamic impact on abdominal aortic aneurysm (AAA) care, often supplanting open AAA repair (OAR). Accordingly, US AAA management is often highlighted by disparities in patient selection and guideline compliance. The purpose of this analysis was to define secular trends in AAA care. METHODS The Society for Vascular Surgery Vascular Quality Initiative was queried for all EVARs and OARs (2011-2021). End points included procedure utilization, change in mortality, patient risk profile, Society for Vascular Surgery-endorsed diameter compliance, off-label EVAR use, cross-clamp location, blood loss, in-hospital complications, and post-EVAR surveillance missingness. Linear regression was used without risk adjustment for all end points except for mortality and complications, for which logistic regression with risk adjustment was used. RESULTS In all, 66 609 EVARs (elective, 85% [n=55 805] and nonelective, 15% [n=9976]) and 13 818 OARs (elective, 70% [n=9706] and nonelective, 30% [n=4081]) were analyzed. Elective EVAR:OAR ratios were increased (0.2 per year [95% CI, 0.01-0.32]), while nonelective ratios were unchanged. Elective diameter threshold noncompliance decreased for OAR (24%→17%; P=0.01) but not EVAR (mean, 37%). Low-risk patients increasingly underwent elective repairs (EVAR, +0.4%per year [95% CI, 0.2-0.6]; OAR, +0.6 points per year [95% CI, 0.2-1.0]). Off-label EVAR frequency was unchanged (mean, 39%) but intraoperative complications decreased (0.5% per year [95% CI, 0.2-0.9]). OAR complexity increased reflecting greater suprarenal cross-clamp rates (0.4% per year [95% CI, 0.1-0.8]) and blood loss (33 mL/y [95% CI, 19-47]). In-hospital complications decreased for elective (0.7% per year [95% CI, 0.4-0.9]) and nonelective EVAR (1.7% per year [95% CI, 1.1-2.3]) but not OAR (mean, 42%). A 30-day mortality was unchanged for both elective OAR (mean, 4%) and EVAR (mean, 1%). Among nonelective OARs, an increase in both 30-day (0.8% per year [95% CI, 0.1-1.5]) and 1-year mortality (0.8% per year [95% CI, 0.3-1.6]) was observed. Postoperative EVAR surveillance acquisition decreased (67%→49%), while 1-year mortality among patients without imaging was 4-fold greater (9.2% versus imaging, 2.0%; odds ratio, 4.1 [95% CI, 3.8-4.3]; P<0.0001). CONCLUSIONS There has been an increase in EVAR and a corresponding reduction in OAR across the United States, despite established concerns surrounding guideline adherence, reintervention, follow-up, and cost. Although EVAR morbidity has declined, OAR complication rates remain unchanged and unexpectedly high. Opportunities remain for improving AAA care delivery, patient and procedure selection, guideline compliance, and surveillance.
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Affiliation(s)
- Brian F. Gilmore
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Florida, USA
| | - Salvatore T. Scali
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Florida, USA
| | - Mario D’Oria
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste ASUGI, Trieste, Italy
| | - Dan Neal
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Florida, USA
| | - Marc L. Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Thomas S. Huber
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Florida, USA
| | - Jesse A. Columbo
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - David H. Stone
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
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Al Tannir AH, Chahrour MA, Chamseddine H, Assi S, Boyajian T, Haddad FF, Hoballah JJ. Outcomes and Cost-Analysis of Open Versus Endovascular Abdominal Aortic Aneurysm Repair in a Developing Country: A 15-year Experience at a Tertiary Medical Center. Ann Vasc Surg 2023; 90:58-66. [PMID: 36309170 DOI: 10.1016/j.avsg.2022.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 09/25/2022] [Accepted: 10/02/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Endovascular aortic aneurysm repair (EVAR) has become the most common procedure for treating abdominal aortic aneurysms based on multiple studies conducted in the western world. The implication of such findings in developing countries is not well demonstrated. The objective of this study was to compare medical outcomes and costs of EVAR and open surgical repair (OSR) in a developing country. METHODS This is a retrospective study of all patients undergoing elective abdominal aortic aneurysm repair between 2005 and 2020 at a tertiary medical center in a developing country. Medical records were used to retrieve demographics, comorbidities, and perioperative complications. Medical records were also used to provide data on the need of reintervention, date of last follow-up, and mortality. RESULTS The study included a total of 164 patients. Median follow-up time was 41 months. The mean age was 69.9 +/- 7.84 years and 90.24% (n = 148) of patients were males. Regarding long-term mortality outcomes, no significant difference was detected between both groups; OSR patients had a survival rate of 91.38% and 74.86% at 5 and 10 years, compared to 77.29% and 56.52% in the EVAR group (P value = 0.10). Both groups had comparable long-term reintervention rates (P value = 0.334). The OSR group was charged significantly less than the EVAR group ($27,666.35 vs. $44,528.04, P value = 0.008). CONCLUSIONS OSR and EVAR have comparable survival and reintervention outcomes. Unlike what was reported in developed countries, patients undergoing OSR in countries with low hospital stay costs incur lower treatment costs.
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Affiliation(s)
| | - Mohamad A Chahrour
- Division of Vascular Surgery, Department of Surgery, University of Iowa Hospital and Clinics, Iowa, IA
| | | | - Sahar Assi
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Talar Boyajian
- Division of Vascular and Endovascular Surgery, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Fadi F Haddad
- Division of Vascular and Endovascular Surgery, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Jamal J Hoballah
- Division of Vascular and Endovascular Surgery, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon.
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Capturing the Complexity of Open Abdominal Aortic Surgery in the Endovascular Era. J Vasc Surg 2022; 76:1520-1526. [PMID: 35714893 DOI: 10.1016/j.jvs.2022.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 05/24/2022] [Accepted: 06/03/2022] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Volume and quality benchmarks for open abdominal aortic surgery and particularly open aortic aneurysm repair (OAR) in the endovascular era are guided by the Society for Vascular Surgery (SVS) guidelines, but the Vascular Quality Initiative (VQI) OAR module fails to capture the full spectrum of complex OAR. We hypothesized that VQI-ineligible complex OAR is the dominant form of open repairs performed at a VQI-participating tertiary center. METHODS All OAR cases performed at a single tertiary care center from 2007 to 2020 were reviewed. The VQI OAR criteria were applied with exclusions (non-VQI) defined as concomitant renal bypass, clamping above the superior mesenteric artery (SMA) or celiac artery, repairs performed for trauma, anastomotic aneurysm, isolated iliac aneurysm, or infected aneurysms. Linear regression was used to assess temporal trends. RESULTS Among a total of 481 open abdominal aortic operations, 355 (74%) were OAR. The average annual OAR volume remained stable over 14 years (25 ± 6; P = .46). Non-VQI OAR comprised 54% of all cases and persisted over time (R2 = .047, P = .46). Supra-celiac clamping (35%) was often necessary. The proportion of endograft explantation cases significantly increased over time from 4% in 2007 to 20% in 2019 (P = .01). Infectious indications represented 20% (n = 70) of cases. Visceral branch grafts were performed in 16% of all cases. OAR for ruptured aneurysm constituted 10% of cases. Thirty-day mortality was significantly higher in non-VQI vs. VQI-eligible OAR cases (10% vs. 4%; P = .04). CONCLUSIONS Complex OAR comprises a majority of OAR cases in a contemporary tertiary referral hospital, yet these cases are not accounted for in the VQI. Creation of a "complex OAR" VQI module would capture these cases in a quality-driven national registry and help to better inform benchmarks for volume and outcomes in aortic surgery.
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Soo Hoo AJ, Fitzgibbon JJ, Hussain MA, Scully RE, Servais AB, Nguyen LL, Gravereaux EC, Semel ME, Marcaccio EJ, Menard MT, Ozaki CK, Belkin M. Contemporary Indications for Open Abdominal Aortic Aneurysm Repair in the Endovascular Era. J Vasc Surg 2022; 76:923-931.e1. [PMID: 35367568 DOI: 10.1016/j.jvs.2022.03.866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 03/21/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION AND OBJECTIVES Despite the emergence of endovascular aneurysm repair (EVAR) as the most common approach to abdominal aortic aneurysm repair, open aneurysm repair (OAR) remains an important option. This study seeks to define the indications for OAR in the EVAR era and how these indications effect outcomes. METHODS A retrospective cohort study was performed of all OAR at a single institution from 2004 to 2019. Pre-operative computed tomography scans and operative records were assessed to determine the indication for OAR. These reasons were categorized into anatomical contraindications; systemic factors (connective tissue disorders, contraindication to contrast dye); and patient/surgeon preference (patients who were candidates for both EVAR and OAR). Perioperative and long-term outcomes were compared between the groups. RESULTS 370 patients were included in the analysis; 71.6% (265/370) had at least one anatomic contraindication to EVAR; 36% had two or more contraindications. The most common anatomic contraindications were short aortic neck length (51.6%), inadequate distal seal zone (19.2%), and inadequate access vessels (15.7%). The major perioperative complication rate was 18.1% and the 30-day mortality was 3.0%. No single anatomic factor was identified as a predictor of perioperative complications. Sixty-one patients (16.5%) had OAR based on patient/surgeon preference; these patients were younger; had lower incidences of coronary artery disease and chronic obstructive pulmonary disease; and they were less likely to require suprarenal cross clamping compared with patients who had anatomic and/or systemic contraindications to EVAR. The patient/surgeon preference group had a lower incidence of perioperative major complications (8.2% versus 20.1%, p=0.034), shorter length of stay (6 versus 8 days, p<0.001) and zero 30-day mortalities. The multivariable adjusted risk for 15-year mortality was lower for patient/surgeon preference patients (adjusted hazard ratio 0.44 [95% confidence interval 0.24-0.80], p=0.007) compared to those anatomic/systemic contraindications. CONCLUSIONS Within a population of patients who did not meet instruction for use (IFU) criteria for EVAR, no single anatomic contraindication was a marker for worse outcomes with OAR. Patients who were candidates for both aortic repair approaches but elected to have open surgical repair due to patient/surgeon preference have very low 30-day mortality and morbidity, and superior long-term survival rates compared with those patients who had OAR due to anatomic and/or systemic contraindications to EVAR.
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Affiliation(s)
- Andrew J Soo Hoo
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, MA
| | - James J Fitzgibbon
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, MA
| | - Mohamad A Hussain
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, MA; Centre for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Rebecca E Scully
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, MA
| | - Andrew B Servais
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, MA
| | - Louis L Nguyen
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, MA
| | - Edwin C Gravereaux
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, MA
| | - Marcus E Semel
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, MA
| | - Edward J Marcaccio
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, MA
| | - Matthew T Menard
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, MA
| | - C Keith Ozaki
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, MA
| | - Michael Belkin
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, MA
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Mehta A, O'Donnell TFX, Schutzer R, Trestman E, Garg K, Mohebali J, Siracuse JJ, Schermerhorn M, Clouse WD, Patel VI. Evaluating Proximal Clamp Site and Intraoperative Ischemia Time Among Open Repair of Juxtarenal Aneurysms. J Vasc Surg 2022; 76:411-418. [PMID: 35149161 DOI: 10.1016/j.jvs.2022.01.126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 01/21/2022] [Indexed: 01/09/2023]
Abstract
INTRODUCTION The proportion of open aneurysm repairs requiring at least a suprarenal clamp has increased in the past few decades, partly due to preferred endovascular approaches for most patients with infrarenal aneurysms, suggesting that the management of aortic clamp placement has become even more relevant. This study evaluated the association between proximal clamp site and intraoperative ischemia times with postoperative renal dysfunction and mortality. METHODS We used the Vascular Quality Initiative to identify all patients undergoing open repairs of elective or symptomatic juxtarenal AAAs from 2004-2018 and compared outcomes by clamp site: above one renal artery, above both renal arteries (supra-renal), or above the celiac trunk (supra-celiac). Outcomes evaluated included acute kidney injury (AKI), new-onset renal failure requiring renal replacement therapy (RRT), 30-day mortality, and one-year mortality. We used multilevel logistic regressions and cox-proportional hazards models, clustered at the hospital level, to adjust for confounding. RESULTS We identified 3976 patients (median age 71 years, 70% male, 8.2% non-Caucasian), with a median aneurysm diameter of 5.9cm (IQR 5.4-6.8cm). Proximal clamp sites were: above one renal artery (31%), supra-renal (52%), and supra-celiac (17%). Rates of unadjusted outcomes were 20.5% for AKI, 4.1% for new-onset RRT, 4.9% for 30-day mortality, and 8.3% for one-year mortality. On adjusted analyses, independent of ischemia time, supra-renal clamping relative to clamping above a single renal artery had higher odds of postoperative AKI (aOR 1.50 [95%-CI 1.28-1.75]) but similar odds for new-onset RRT (aOR 1.27 [0.79-2.06]) and 30-day mortality (aOR 1.12 [0.79-1.58]) and hazards for one-year mortality (aHR 1.12 [0.86-1.45]). However, every ten minutes of prolonged intraoperative ischemia time was associated with an increase in odds or hazards ratio of postoperative AKI by +7% (IQR 3-11%), new-onset RRT by +11% (IQR 4-17%), 30-day mortality by +11% (IQR 6-17%), and one-year mortality by +7% (IQR 2-13%). Patients with greater than 40 minutes of ischemia time had notably higher rates of all four outcomes. DISCUSSION Supra-renal clamping relative to clamping above a single renal artery was associated with AKI but not new-onset RRT or 30-day mortality. However, intraoperative renal ischemia time was independently associated with all four postoperative outcomes. While further studies are warranted, our findings suggest that an expeditious proximal anastomosis creation is more important than trying to maintain clamp position below one renal artery, suggesting that suprarenal clamping may be the best strategy for open AAA repair when needed to efficiently perform the proximal anastomosis.
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Affiliation(s)
- Ambar Mehta
- Division of Cardiac, Thoracic, and Vascular Surgery, New York Presbyterian/Columbia University Medical Center/Columbia University College of Physicians and Surgeons, New York, NY
| | - Thomas F X O'Donnell
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Richard Schutzer
- Division of Cardiac, Thoracic, and Vascular Surgery, New York Presbyterian/Columbia University Medical Center/Columbia University College of Physicians and Surgeons, New York, NY
| | - Eric Trestman
- Division of Cardiac, Thoracic, and Vascular Surgery, New York Presbyterian/Columbia University Medical Center/Columbia University College of Physicians and Surgeons, New York, NY
| | - Karan Garg
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Jahan Mohebali
- Division of Vascular and Endovascular Surgery, NYU Langone Medical Center, New York, NY
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston University Medical Center, Boston, MA
| | - Marc Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - William D Clouse
- Division of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA
| | - Virendra I Patel
- Division of Cardiac, Thoracic, and Vascular Surgery, New York Presbyterian/Columbia University Medical Center/Columbia University College of Physicians and Surgeons, New York, NY.
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Jacobs CR, Scali ST, Khan T, Cadavid F, Staton KM, Feezor RJ, Back MR, Upchruch GR, Huber TS. EVAR Conversion is an Increasingly Common Indication for Open AAA Repair. J Vasc Surg 2021; 75:144-152.e1. [PMID: 34314833 DOI: 10.1016/j.jvs.2021.07.121] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 07/15/2021] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Although EVAR re-intervention is common, conversion to open repair(EVAR-c) occurs less frequently but can be associated with significant technical complexity and perioperative risk. There is a paucity of data highlighting the evolution of peri-procedural results surrounding EVAR-c and change in practice patterns, especially for referral centers that increasingly manage EVAR failures. The purpose of this analysis was to perform a temporal analysis of our EVAR-c experience and describe changes in patient selection, operative details and outcomes. METHODS A retrospective single center review of all open AAA repairs was performed(2002-2019) and EVAR-c procedures were subsequently analyzed. EVAR-c patients(n=184) were categorized into two different eras(2002-2009, n=21; 2010-2019, n=163) for comparison. Logistic regression and Cox proportional hazards modeling were used for risk-adjusted comparisons. RESULTS A significant increase in EVAR-c as an indication for any type of open aneurysm repair was detected(9%→27%;p<.001). Among EVAR-c patients, no change in age or individual comorbidities was evident[mean age: 71±9 years]; however, the proportion of female subjects(p=.01) and ASA classification >3 declined(p=.05). There was no difference in prevalence[50% vs. 43%;p=.6] or number[median-1.5(0, 5)] of pre-admission EVAR re-interventions; however, time to re-intervention decreased(median: 23[6,34] vs. 0[0,22] months;p=.005). In contrast, time to EVAR-c significantly increased(median: 16[9,39]vs. 48[20,83]-months;p=.008). No difference in frequency of non-elective presentation[mean-52%;p=.9] or indication was identified but a trend toward increasing mycotic EVAR-c was observed(5% vs. 15%;p=.09). Use of retroperitoneal exposure(14% vs. 77%;p<.0001), suprarenal cross-clamp application[6286%;p=.04] and visceral-ischemia time(median: 0[0,11] vs. 5[0,20]min;p=.05) all increased. In contrast, estimated blood loss(P-trend=.03) and procedure-time(p=.008) decreased. The unadjusted elective 30-day mortality rate improved but did not reach statistical significance[elective: 10% vs. 5%;p=.5] with no change for non-elective operations[18% vs. 16%;p=.9]. However, a significantly decreased risk of complications was evident(OR 0.88, 95%CI .8-.9;p=.01). One and 3-year survival was similar over time. CONCLUSION EVAR-c is now a common indication for open AAA repair. Patients frequently present non-electively and at increasingly later intervals after their index EVAR. Despite increasing technical complexity, decreased complication risk and comparable survival can be anticipated when patients are managed at a high-volume aortic referral center.
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Affiliation(s)
- Christopher R Jacobs
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville
| | - Salvatore T Scali
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville.
| | - Tabassum Khan
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville
| | - Felipe Cadavid
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville
| | - Kyle M Staton
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville
| | - Robert J Feezor
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville
| | - Martin R Back
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville
| | - Gilbert R Upchruch
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville
| | - Thomas S Huber
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville
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Blackstock CD, Jackson BM. Open Surgical Repair of Abdominal Aortic Aneurysms Maintains a Pivotal Role in the Endovascular Era. Semin Intervent Radiol 2020; 37:346-355. [PMID: 33041480 DOI: 10.1055/s-0040-1715881] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Since the advent of endovascular aortic repair (EVAR) nearly three decades ago, there has been a paradigm shift in the treatment of the abdominal aortic aneurysm (AAA) to favor EVAR due to its reduced operative mortality, less invasive nature, and faster recovery times. However, more recently there has been an accumulation of data from large meta-analyses and randomized clinical trials revealing that EVAR has no survival benefit after approximately 2 years and is associated with substantially higher rates of reintervention and aneurysm rupture in the long term. These findings call into question the durability of EVAR compared with open aortic repair and emphasize the need for surgeons to remain competent with open aortic surgery in the modern era. This article will provide comprehensive review of a large body of literature comparing endovascular repair to open aortic surgery for the management of AAAs, and it will offer an overview of the open surgical repair technique for AAAs.
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Affiliation(s)
- Christopher D Blackstock
- Division of Vascular Surgery and Endovascular Therapy, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Benjamin M Jackson
- Division of Vascular Surgery and Endovascular Therapy, University of Pennsylvania, Philadelphia, Pennsylvania
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