Does the wide application of endovascular AAA repair affect the results of open surgery?

ADAR1 Non-Editing Function in Macrophage Activation and Abdominal Aortic Aneurysm

BACKGROUND

Macrophage activation plays a critical role in abdominal aortic aneurysm (AAA) development. However, molecular mechanisms controlling macrophage activation and vascular inflammation in AAA remain largely unknown. The objective of the study was to identify novel mechanisms underlying adenosine deaminase acting on RNA (ADAR1) function in macrophage activation and AAA formation.

METHODS

Aortic transplantation was conducted to determine the importance of nonvascular ADAR1 in AAA development/dissection. Ang II (Angiotensin II) infusion of ApoE-/- mouse model combined with macrophage-specific knockout of ADAR1 was used to study ADAR1 macrophage-specific role in AAA formation/dissection. The relevance of macrophage ADAR1 to human AAA was examined using human aneurysm specimens. Moreover, a novel humanized AAA model was established to test the role of human macrophages in aneurysm formation in human arteries.

RESULTS

Allograft transplantation of wild-type abdominal aortas to ADAR1+/- recipient mice significantly attenuated AAA formation, suggesting that nonvascular ADAR1 is essential for AAA development. ADAR1 deficiency in hematopoietic cells decreased the prevalence and severity of AAA while inhibited macrophage infiltration and aorta wall inflammation. ADAR1 deletion blocked the classic macrophage activation, diminished NF-κB (nuclear factor kappa B) signaling, and enhanced the expression of a number of anti-inflammatory microRNAs. Mechanistically, ADAR1 interacted with Drosha to promote its degradation, which attenuated Drosha-DGCR8 (DiGeorge syndrome critical region 8) interaction, and consequently inhibited pri- to pre-microRNA processing of microRNAs targeting IKKβ, resulting in an increased IKKβ (inhibitor of nuclear factor kappa-B) expression and enhanced NF-κB signaling. Significantly, ADAR1 was induced in macrophages and interacted with Drosha in human AAA lesions. Reconstitution of ADAR1-deficient, but not the wild type, human monocytes to immunodeficient mice blocked the aneurysm formation in transplanted human arteries.

CONCLUSIONS

Macrophage ADAR1 promotes aneurysm formation in both mouse and human arteries through a novel mechanism, that is, Drosha protein degradation, which inhibits the processing of microRNAs targeting NF-kB signaling and thus elicits macrophage-mediated vascular inflammation in AAA.

Long-term Outcomes after FEVAR for Juxtarenal Aortic Aneurysm

OBJECTIVE

Fenestrated endovascular aortic repair (FEVAR) for juxtarenal aortic aneurysm (jAAA) disease is safe and effective with good short- and mid-term outcomes. Durability issues focus mainly on proximal and distal seal as well as target vessel (TV) instability, and long-term data is scarce. In previous publications we have reported short-term outcomes after FEVAR while comparing early- and late-experience patient groups, as well as long-term results for the early cohort. In this series we provide long-term outcome in the late experience cohort treated with FEVAR in Vascular Center Malmö.

METHODS

Consecutive patients treated in Vascular Center Malmö with FEVAR for jAAA between 2007 and 2011 were included. Data was collected retrospectively from medical- and imaging records. Follow up consisted of a clinical examination 1 month post-operatively, and computed tomography angiography combined with plain abdominal X-ray at 1 and 12 months, and annually thereafter. Primary endpoints were TV instability, reinterventions and survival. Changes in aneurysm diameter and renal function as well as endoleaks were also analyzed.

RESULTS

94 patients were treated. Median follow-up time was 89 (range 0-152) months. 280 fenestrations or scallops were employed of which 205 were stented. Technical success was 89.4%. Primary TV patency was 94% ± 1 % at 1year, 90% ± 2% at 3 years and 89% ± 2% at 5 years. 37 (39.4%) patients needed a total of 70 reinterventions and mean time to first reintervention was 21 ± 3.97 months. 5 (5.3%) patients died of aneurysm related causes and overall survival was 95.7% ± 2.1% at 1 year, 87.1% ± 3.5% at 3 years and 71.0 ± 4.7% at 5 years. A stable or decreasing aortic diameter after treatment was seen in 91% of cases. Mean glomerular filtration rate (GFR) fell from 59.2 ± 14.9 ml/min/1.73m² pre-operatively to 50.0 ± 18.6 ml/min/1.73 m² at end of follow-up.

CONCLUSION

Long-term results after treatment of jAAA with FEVAR remain good and the treatment is safe and effective. Although the need for reintervention remains high, long-term renal function and survival support the use of FEVAR as a valid treatment option for jAAA disease.

What Did Endovascular Aortic Repair Bring for the Treatment Strategy of Abdominal Aortic Aneurysm?

Objective: We examined the effects of the introduction of endovascular aortic repair (EVAR) on treatment for abdominal aortic aneurysms (AAAs).

Subjects: We compared patients in the following three periods: period I (January 2002–December 2006, 105 patients), period II (January 2007–December 2011, 242 patients, duration of 5 years after the introduction of EVAR), and period III (January 2012–December 2016, 237 patients, duration of 5 years after period II). We used the American Society of Anesthesiologists (ASA) classification for risk assessment.

Results: In the Open repair (OR) group, the incidences of ASA class 2 increased and classes 3 and 4 decreased significantly in periods II and III compared with period I. In all periods, there were no in-hospital deaths. Suprarenal aortic cross-clamping was required in 18 patients (19.1%) in period III and 5 patients (6.3) in period I, and the difference was significant (P<0.05). In the EVAR group, no differences in age, sex, or ASA classification class were observed between periods II and III. In period II, one patient died due to aneurysm rupture during surgery. Significant differences were observed when comparing both groups in periods II and III: patients in the EVAR group were older (P<0.01) and the OR group had a higher proportion of ASA class 2 patients and the EVAR group had a higher proportion of ASA class 3 or 4 patients (P<0.01). Among all AAA surgeries, rupture occurred in 25 patients (23.8%) in period I, 18 patients (7.4) in period II, and 16 patients (6.8) in period III. The number of ruptures was significantly lower in periods II and III than in period I (P<0.01).

Conclusions: The findings of this study suggest that EVAR should be indicated for high-risk patients and had the good outcome of AAA treatment. (This is a translation of Jpn J Vasc Surg 2018; 27: 27–32.)

Repair of a bowel-containing, scrotal hernia with incarceration contributed by femorofemoral bypass graft

The rising use of endovascular techniques utilizing femoral artery access may increase the frequency with which surgeons face the challenge of hernia repair in reoperative groins—which may or may not include a vascular graft. We present a case where a vascular graft contributed to an acute presentation and complicated dissection, and review the literature. A 67-year-old man who had undergone prior endovascular aneurysm repair via open bilateral femoral artery access and concomitant prosthetic femorofemoral bypass, presented with an incarcerated, scrotal inguinal hernia. The graft with its associated fibrosis contributed to the incarceration by compressing the inguinal ring. Repair was undertaken via an open, anterior approach with tension-free, Lichtenstein herniorraphy after releasing graft-associated fibrosis. Repair of groin hernias in this complex setting requires careful surgical planning, preparation for potential vascular reconstruction and meticulous technique to avoid bowel injury in the face of a vascular conduit and mesh.

The Influence of Endovascular Techniques on Our Surgical Practice: A 10-Year View

Advances in catheter technology, gene identification, and cell biology may provide novel treatment options for patients with peripheral arterial disease (PAD) who are not candidates for standard revascularization procedures. Animal studies and recent results in human beings suggest that transfer of growth factors or regulatory genes and transplantation of progenitor cells may provide novel therapy options by inducing therapeutic angiogenesis or by inhibiting restenosis. This review will discuss the development of a variety of catheters for localized endovascular delivery, as well as the various cellular and genetic strategies that exist to restore blood flow to ischemic tissue and to reduce neointimal hyperplasia.

Abdominal Aortic Aneurysm Repair: Results from a Series of Young Patients

Objectives. To compare durability and survival after endovascular aneurysm repair (EVAR) and open repair (OR) of abdominal aortic aneurysms (AAAs) in young patients. Material and Methods. A retrospective study was conducted between 2005 and 2014 on all consecutive patients of 60 years of age or younger. Measures considered for analysis were reintervention related to AAA, laparotomy and access vessel injury during EVAR, and all-cause mortality during hospitalization and follow-up. Results. Seventy out of 119 patients were treated by OR (58.8%) and 49 (41.2%) by EVAR, 9 in off-label fashion (18.3%). Technical success was achieved in all cases. No AAA-related death was recorded. Overall in-hospital mortality was zero and the reintervention rate was 2.5% (3/119: 1/70 OR, 2/49 EVAR, p = 0.36). There is no death at 30-day or 1-year follow-up. Thirty-day reintervention rate was 1.6% (2/119; 0/70 OR, 2/49 EVAR, p = 0.16), while the 1-year rate was 2.5% (3/119; 1/70 OR, 2/49 EVAR, p = 0.36). At the mean follow-up of 56.8 ± 42.7 months, mortality and reintervention rates were 5.8% (7/119; 3/70 OR, 4/49 EVAR, p = 0.38) and 10% (12/119; 8/70 OR, 4/49 EVAR, p = 0.39), respectively. The overall reintervention rate, mortality, and freedom from adverse events did not differ between the two groups. No differences in outcome were recorded between patients treated by EVAR in on-label versus off-label fashion. Conclusion. Our (albeit limited) experience suggests that, in an unselected young patient population undergoing elective AAA repair, OR or EVAR can be performed safely with similar immediate and long term outcomes.

Outcome and complications after intra-arterial thrombolysis for lower limb ischaemia with or without continuous heparin infusion

Background

Thrombolysis is a common treatment for acute leg ischaemia. The purpose of this study was to evaluate different thrombolytic treatment strategies, and risk factors for complications.

Methods

This was a retrospective analysis of prospective databases from two vascular centres. One centre used a higher dose of heparin and recombinant tissue plasminogen activator (rtPA).

Results

Some 749 procedures in 644 patients of median age 73 years were studied; 353 (47·1 per cent) of the procedures were done in women. The aetiology of ischaemia was graft occlusion in 38·8 per cent, acute arterial thrombosis in 32·2 per cent, embolus in 22·3 per cent and popliteal aneurysm in 6·7 per cent. Concomitant heparin infusion was used in 63·2 per cent. The mean dose of rtPA administered was 21·0 mg, with a mean duration of 25·2 h. Technical success was achieved in 80·2 per cent. Major amputation and death within 30 days occurred in 13·1 and 4·4 per cent respectively. Bleeding complications occurred in 227 treatments (30·3 per cent). Blood transfusion was needed in 104 (13·9 per cent). Three patients (0·4 per cent of procedures) had intracranial bleeding; all were fatal. Amputation-free survival was 83·6 per cent at 30 days at both centres. In multivariable analysis, preoperative severe ischaemia with motor deficit was the only independent risk factor for major bleeding (odds ratio (OR) 2·98; P <0·001). Independent risk factors for fasciotomy were severe ischaemia (OR 2·94) and centre (OR 6·50). Embolic occlusion was protective for major amputation at less than 30 days (OR 0·30; P = 0·003). Independent risk factors for death within 30 days were cerebrovascular disease (OR 3·82) and renal insufficiency (OR 3·86).

Conclusion

Both treatment strategies were successful in achieving revascularization with acceptable complication rates. Continuous heparin infusion during intra-arterial thrombolysis appeared to offer no advantage.

Comparison of fenestrated endovascular and open repair of abdominal aortic aneurysms not suitable for standard endovascular repair

BACKGROUND

Abdominal aortic aneurysms that are unsuitable for a standard endovascular repair (EVAR) could be considered for fenestrated endovascular repair (f-EVAR). The aim of this study was to conduct a risk-adjusted retrospective concurrent cohort comparison of f-EVAR and open repair for such aneurysms.

METHODS

All patients who underwent repair of an abdominal aortic aneurysm that was unsuitable for a standard EVAR due to inadequate neck within one institution between January 2006 and December 2010 were identified. Case notes were retrieved for clinical data, Vascular Physiological and Operative Severity Score for enUmeration of Mortality and Morbidity (V-POSSUM) score, and aneurysm morphology. Computed tomography scans were reviewed to establish aneurysm morphology.

RESULTS

A total of 107 patients were identified. The open surgery cohort included 54 patients (35 men) who were a median age of 72 years (interquartile range [IQR], 9.5; range, 60-86 years). The aortic cross-clamp was infrarenal in 20 patients, suprarenal or above in 21, and inter-renal in eight. Postoperatively, 63 major complications were noted in 30 patients, nine of whom required 16 reinterventions. Cumulative hospital stay of the cohort was 1170 days (median, 12; IQR, 13; range, 1-205 days) of which 234 days (median, 28; IQR, 36; range, 1-77 days) were in the intensive therapy unit (ITU). Perioperative mortality was 9.2% (n = 5), exactly as estimated by V-POSSUM. The f-EVAR cohort included 53 patients (47 men) who were a median age of 76 years (IQR, 11.50; range, 55-87 years). Two fenestrations and one scallop was the most frequent configuration (n = 31). Postoperatively, 37 major complications were noted in 18 patients, six requiring reintervention. Hospital stay was 559 days (median, 7; IQR, 4.5; range, 4-64 days), of which 31 days (median, 4; IQR, 10.5; range, 1-15 days) were in the ITU. Two patients died perioperatively (3.7%), resulting in an observed crude absolute risk reduction of 5.5% compared with open repair. The V-POSSUM estimated perioperative death in five patients (9.4%) in the f-EVAR cohort. In a hypothetic scenario of the f-EVAR cohort undergoing open repair, V-POSSUM estimated seven deaths (13.2%), resulting in an estimated risk-adjusted absolute risk reduction due to f-EVAR of 9.5%.

CONCLUSIONS

In this group of patients, f-EVAR reduced mortality and morbidity substantially compared with open repair and also reduced total hospital stay and ITU utilization.

Effects of study design and trends for EVAR versus OSR

Purpose:

To investigate if study design factors such as randomization, multi-center versus single center evidence, institutional surgical volume, and patient selection affect the outcomes for endovascular repair (EVAR) versus open surgical repair (OSR). Finally, we investigate trends over time in EVAR versus OSR outcomes.

Methods:

Search strategies for comparative studies were performed individually for: OVID’s MEDLINE, EMBASE, CINAHL, HAPI, and Evidence Based Medicine (EBM) Reviews (including Cochrane DSR, ACP Journal Club, DARE and CCTR), limited to 1990 and November 2006.

Results:

Identified literature: 84 comparative studies pertaining to 57,645 patients. These include 4 randomized controlled trials (RCTs), plus 2 RCTs with long-term follow-up. The other 78 comparative studies were nonrandomized with 75 reporting perioperative outcomes, of which 16 were multi-center, and 59 single-center studies. Of the single-center studies 31 were low-volume and 28 were high-volume centers. In addition, 5 studies had all patients anatomically eligible for EVAR, and 8 studies included high-risk patients only. Finally, 25 long term observational studies reported outcomes up to 3 years.

Outcomes:

Lower perioperative mortality and rates of complications for EVAR versus OSR varied across study designs and patient populations. EVAR adverse outcomes have decreased in recent times.

Conclusion:

EVAR highlights the problem of performing meta-analysis when the experience evolves over time.

EVAR and complex anatomy: an update on fenestrated and branched stent grafts

Endovascular aneurysm repair (EVAR) offers a minimally invasive treatment to patients with improved short-term and similar mid-term results compared to conventional, open repair (OR). EVAR is preferred by patients due to the reduction of surgical trauma. Approximately 20% of patients have aneurysm neck morphology which is inadequate for a standard stent graft and requires the endograft to cross vital aortic side branches to achieve a seal. This chapter describes the evolution of three types of devices, namely the fenestrated and branched stent grafts as well as the chimney grafts. These stent grafts incorporate vital aortic side branches in the repair, thereby increasing the applicability of EVAR which may improve the overall results.

Predictors for Outcome after Open and Endovascular Repair of Ruptured Abdominal Aortic Aneurysms

OBJECTIVES

The aims of the present study were to analyze patient- and management-related predictors for outcome after open (OR) and endovascular repair (EVAR) of ruptured abdominal aortic aneurysm (rAAA).

DESIGN

Retrospective study.

MATERIALS

The in-hospital registry of Malmö University Hospital identified 162 patients operated on due to rAAA between 2000 and 2004.

METHODS

Patient- and management-related predictors for outcome were analysed.

RESULTS

Preoperative CT in 39 out of 62 circulatory unstable patients was not associated with increased mortality (p=0.60). There was a significant increase in repairs performed by EVAR during the study period (p<0.001), and in 2004 EVAR exceeded the annual rate of OR. Patients in the EVAR group were older (p=0.025), whereas patients in the OR group more often suffered from unconsciousness after presentation (p=0.004). Age, unconsciousness after presentation and haemoglobin were significantly associated with in-hospital mortality when tested in a multivariate logistic regression model (p=0.002, p=0.003 and p<0.001, respectively). The in-hospital mortality for patients undergoing OR and EVAR was 45% (48/106) and 34% (19/56), respectively (p=0.16). Diagnosis of abdominal compartment syndrome (p=0.005) and intestinal infarction (p=0.002) was associated with poor survival.

CONCLUSIONS

Patient-related factors such as age, loss of consciousness and haemoglobin predicts outcome in a population where both emergency OR and EVAR for the treatment of rAAA is feasible.

The Hardman index in patients operated on for ruptured abdominal aortic aneurysm: A systematic review

BACKGROUND

The aims of the present study were to (1) analyze preoperative predictors for outcome suggested by Hardman and surgical mortality after open repair and endovascular repair (EVAR) of ruptured abdominal aortic aneurysms (rAAA), and (2) further evaluate the Hardman index in a systematic review.

METHODS

Patients operated on for rAAA during a 5-year period between 2000 and 2004 were scored according to Hardman-1 point for either age >76 years, loss of consciousness after presentation, hemoglobin <90 g/L, serum creatinine >190 micromol/L or electrocardiographic (ECG) signs of ischemia-with blinded evaluation of ECGs by a specialist in clinical physiology. The results were included in a systematic review of studies evaluating the Hardman index.

RESULTS

In-hospital mortality after operation was 41% (67/162). There was no difference in in-hospital mortality between open repair (n = 106) and EVAR (n = 56), whereas the Hardman index was associated with operative mortality in our institution and in the systematic review of 970 patients (P < .001). Mortality rate in patients with Hardman index > or =3 was 77% in the pooled analysis. A full data set of all five scoring variables was obtained in 94 (58%) of 162 patients in our study, and potential underscoring was thus possible in 68 patients. Of the available ECGs, 12 (8.7%) of 138 were judged nondiagnostic. Five studies did not state their missing data on ECG and hemoglobin and serum creatinine concentrations, nor did they specify the criteria for ECG ischemia.

CONCLUSIONS

A strong correlation between the Hardman index and mortality was found. A Hardman index > or =3 cannot be used as an absolute limit for denial of surgery. The utility of the Hardman index seems to be impeded by variability in scoring resulting from missing or nondiagnostic data.

Increasing incidence of ruptured abdominal aortic aneurysm: A population-based study

OBJECTIVE

The aim of the present population-based study was to assess the trends of age- and gender-specific incidence of ruptured abdominal aortic aneurysm (rAAA).

METHODS

Patients with rAAA from the city of Malmö, Sweden, were studied between 2000 and 2004. An analysis of trends of incidence and mortality of rAAA in Malmö was possible because of a previous population-based study on patients with rAAA between 1971 and 1986 (autopsy rate 85% compared with 25% for the time period 2000 to 2004). The in-hospital registry of Malmö University Hospital and the databases at the Department of Pathology, Malmö, and the Institution of Forensic Medicine, Lund, identified patients with rAAA, and the in-hospital registry identified all elective repairs for AAA.

RESULTS

Compared with the time period 1971 to 1986, the overall incidence of rAAA significantly increased from 5.6 (95 % confidence interval [CI], 4.9 to 6.3) to 10.6 (95% CI, 8.9 to 12.4) per 100,000 person-years (standardized mortality ratio, 1.6; 95% CI, 1.0 to 2.1). In men aged 60 to 69 and 70 to 79 years, the incidence increased significantly from 16 (95% CI, 11 to 21) and 56 (95% CI, 43 to 69) to 46 (95% CI, 28 to 63) and 117 (95% CI, 84 to 149) per 100,000 person-years, respectively, whereas no increase in the age-specific incidence in women could be demonstrated. The overall incidence of elective repair of AAA increased significantly from 3.4 (95% CI, 2.8 to 4.0) to 7.0 (95% CI, 5.6 to 8.4) per 100,000 person-years and increased most significantly from 12 (95% CI, 3.4 to 32) to 68 (95% CI, 34 to 102) per 100,000 person-years in men aged 80 to 89 years and from 5.1 (95% CI, 2.4 to 9.3) to 28 (95% CI, 15 to 41) per 100,000 person-years in women aged 70 to 79 years. The elective-acute repair ratio in women increased from 2.4 to 5.6 and decreased in men from 2.1 to 1.0.

CONCLUSIONS

Between 1971 to 1986 and 2000 to 2004, the incidence of rAAA increased significantly, despite a 100% increase in elective repairs and notwithstanding a potential for bias towards underestimation due to lower autopsy rates in recent years. The reason behind this increase is unclear, and further studies are needed to identify risk groups for direction of effective prevention and screening.

Percutaneous thrombin injection to complete SMA pseudoaneurysm exclusion after failing of endograft placement

Visceral aneurysms are potentially life-threatening vascular lesions. Superior mesenteric artery (SMA) pseudoaneurysms are a rare but well-recognized complication of chronic pancreatitis. Open surgical repair of such an aneurysm, especially in patients after previous surgical treatment, might be dangerous and risky. Stent graft implantation makes SMA pseudoaneurysm exclusion possible and therefore avoids a major abdominal operation. Percutaneous direct thrombin injection is also one of the methods of treating aneurysms in this area. We report a first case of percutaneous ultrasound-guided thrombin injection to complete SMA pseudoaneurysm exclusion after an unsuccessful endograft placement. Six-month follow-up did not demonstrate any signs of aneurysm recurrence.

Clinical effect of abdominal aortic aneurysm endografting: 7-year concurrent comparison with open repair

OBJECTIVE

We compared the effectiveness and clinical outcome of open repair versus endovascular aortic aneurysm repair (EVAR) in achieving prevention of abdominal aortic aneurysm (AAA)-related death and graft-related complications.

METHODS

Over 7 years from 1997 to 2003, 1119 consecutive patients underwent elective treatment of infrarenal AAAs, 585 with open repair and 534 with EVAR. Patients were regularly followed up at 1, 6, 12 months, and every 6 months thereafter, in EVAR group, and at 3 and 12 months, and yearly thereafter after open repair. Preoperative, intraoperative, and follow-up data were stored in a prospective database.

RESULTS

Median follow-up was similar in the 2 groups: 33 months (interquartile range [IQR], 13-50 months) in the EVAR group vs 35 months (IQR, 15-54 months) in the open repair group. EVAR group patients were older than patients in the open repair group: 73 years vs 72 years (P = .04). There were statistical significant differences between the EVAR group and the open repair group with respect to AAA median diameter (52 mm vs 56 mm), coronary disease rate (46% vs 37%; P = .001), pulmonary disease rate (56% vs 38%; P < .0001), and American Society of Anesthesiologists IV score rate (16% vs 6%; P < .0001). Thirty-day mortality in the EVAR group was 0.9% (5 of 534 patients), compared with 4.1% (24 of 585 patients; P = .001) in the open repair group, and major morbidity was 9.1% (49 of 534 patients) vs 18.6% (109 of 585 patients; P < .0001), respectively. The incidence of secondary procedures in the EVAR group was 15.7%, compared with 3% in the open repair group (P < .0001). There were no deaths related to secondary procedures in either group. Six AAAs (1.1%) ruptured after EVAR, 3 of which were fatal; in the open repair group 1 patient (0.2%) underwent successful repeat operatation to treat iliac pseudoaneurysm rupture 5 years after the original procedure. Kaplan-Meier estimates for freedom from aneurysm-related death at 84 months were 97.5% in the EVAR group and 95.9% in the open repair group (log rank test, P = .008). Kaplan-Meier survival estimates at 84 months were 67.1% in the open repair group and 66.9% in the EVAR group (P = NS). At the same interval the risk for secondary procedures was 49.4% for the EVAR group and 7.1% for the open repair group. Of the 11 variables analyzed with logistic analysis, open surgery (hazard ratio [HR], 11; 95% confidence interval [CI], 2.5-54.2; P = .002), American Society of Anesthesiologists IV score (HR, 7.1; 95% CI, 2.7-18.8; P = .0001), and age (HR, 1.06; 95% CI, 1.04-1.13; P = .04) were positive independent predictors of perioperative mortality.

CONCLUSION

Our data suggest that at a maximum follow-up of 7 years, patients who undergo EVAR show lower perioperative and late aneurysm-related mortality compared with a younger and substantially healthier group of patients with aneurysms treated with open repair. The higher need for secondary procedures in the endovascular group did not affect superiority of the overall performance of EVAR in the early and late intervals.