Are concerns about EVAR durability relevant with modern devices?

Endovascular aneurysm repair (EVAR) is now universally adopted as first-line therapy for the management of large abdominal aortic aneurysms (AAA). The applicability has broadened such that up to 80% of patients are morphologically suitable for EVAR. In-spite of the evidence base demonstrating improved early outcomes following EVAR compared to open surgery, and informed patients' preference, EVAR-sceptics remain. The doubters voice anxieties regarding the durability of an endovascular repair and cite evidence of graft failures from the EVAR-1 trial results. Historically, graft migration and endoleak development have been the Achilles heel of EVAR. However, EVAR is an evolving technology that over the last 10 years has seen significant development from industry, and greater experience among clinicians. This has combined with centralisation of expertise in larger vascular units, with increased case-volume, leading to more appropriate periprocedural and long-term care. Current devices offer a durable repair for patients with infra-renal aortic aneurysms. The risk of graft migration is minimised by devices with secure fixation systems, potentially limiting de-novo type 1 and 3 endoleaks. Appropriate surveillance and timely endovascular re-interventions are perhaps the most important factors to ensure robust long-term outcomes from endovascular repair, even when native vessel morphology changes. Industry registry evidence and large single unit case series are now generating a healthy evidence base of EVAR durability in contemporary endovascular practice, that affirms its role as first-line therapy in the majority of morphologically suitable patients.

Patient-reported symptoms are independent of disease severity in patients with primary varicose veins

The objective of this paper is to explore patterns of incompetence and disease distribution in patients with chronic venous disorders and to correlate this with CEAP (Clinical, Etiologic, Anatomic and Pathologic) classification and presenting symptoms to determine which features of chronic venous disorder (CVD) could be used to guide a patient pathway for referral and treatment. Consecutive patients attending a one-stop venous clinic at a university teaching hospital were recruited over a 12-month period. Patients were clinically assessed, assigned CEAP scores, duplex-scanned and categorized. Data were analyzed to identify associations between symptomatology and disease. Four hundred twenty-four limbs were divided into groups A (C2–3) (339) and B (C4–6) (85). The number of men, mean patient age, varicose vein diameter and quality-of-life score (Aberdeen Varicose Vein Questionnaire – AVVS) were significantly higher in group B ( P < 0.01). Ache occurred more commonly in group A and in women ( P < 0.01). Ache and pain were seen more frequently with saphenofemoral junction reflux ( P < 0.05). Group A women were more likely to be offered surgical intervention while men were managed conservatively ( P < 0.05). In conclusion, CVD symptoms are independent of disease severity assessed by CEAP score. Advanced disease is associated with larger venous diameters, older age and corresponds to a poorer quality of life. Objective markers such as CEAP, Venous Clinical Severity Score and AVVS should be used in determining a patient pathway for referral and treatment of CVD.

Should the role of EVAR be re-evaluated in light of the 10 year results of EVAR-1?

EVAR-1 published its 10 year results in 2010. The principal finding of the study was that the endovascular group (EVR) had a significant reduction in early aneurysm related mortality compared to open surgery (OR), but the benefit was lost by the end of the study (adjusted hazard ratio [HR], 0.92; 95% confidence interval [CI] 0.57-1.49; P=0.73). By the end of follow-up, there was no significant difference between the OR and EVR group in terms of death from any cause (HR 1.03; 95% CI 0.86-1.23; P=0.72). Despite these findings the uptake of EVR continues to increase. EVR is driving improved surgical outcomes in elective abdominal aortic aneurysm (AAA) surgery, and may yet establish itself as an essential tool in the emergency setting. Elective AAA mortality may be reducing in the U.K. as a consequence of broader application of EVR. This article presents and examines the EVAR-1 data and reports the additional wealth of evidence supporting EVR from prospective registries. It proposes that EVR should be re-evaluated, but not as a consequence of the long-term EVAR-1 results. Clinicians' expertise, understanding and the technology of EVR have progressed significantly since the establishment of the EVAR-1 trial, such that the results, though valuable, may not translate to modern practice. It is essential to maintain excellence in vascular surgery and the evidence-base now demonstrates that best practice in AAA management is in specialist vascular centres, performing high volume surgery offering EVR to all patients who are morphologically suitable.

The requirement for smart catheters for advanced endovascular applications

Endovascular techniques are well established in minimally invasive vascular surgery. Stent-graft technology is evolving. This will allow more complex aortic pathology to be treated. Current limitations in this equipment include the reliance on selective catheters along with trial and error to cannulate visceral or aortic arch branch vessels. This can lead to prolonged operations with increased radiation and contrast load to the patient with inevitable increase in peri-operative morbidity. A smart catheter that could expedite target vessel catheterization, minimize repeat catheter changes, and provide greater haptic feedback would enhance the endovascular surgeon's armamentarium. This would lead to broader and safer application of endovascular surgery.

Risk of reintervention after endovascular aortic aneurysm repair

BACKGROUND

The role of symptomatic presentation in directing reintervention after endovascular aortic aneurysm repair (EVAR) was investigated.

METHODS

All patients undergoing infrarenal EVAR between 2001 and 2009 were studied. Those needing reintervention were divided into symptomatic and asymptomatic presentations. Kaplan-Meier survival curves were used to calculate freedom from reintervention, and log rank tests for subgroup analyses. Multivariable analysis identified risk factors for reintervention.

RESULTS

The study included 553 patients with a mean(s.d.) age of 75(7) years and aneurysm diameter of 65(13) mm. The 30-day mortality rate was 2.5 per cent. Median follow-up was 31 (range 1-97) months. There were 86 reinterventions in 69 (12.5 per cent) of 553 patients; 41 presented with symptoms and 28 were asymptomatic. Reintervention-free survival rates at 1, 3 and 5 years were 90.1, 85.3 and 81.2 per cent. The reintervention rate was higher in patients who needed an intraoperative adjunct during the index procedure (P = 0.014) and in those who did not have intraoperative computed tomography angiography (P = 0.024). Intraoperative adjuncts were an independent risk factor for future reintervention (hazard ratio 2.62, 95 per cent confidence interval 1.18 to 3.76; P = 0.012).

CONCLUSION

Most patients requiring reintervention presented symptomatically. A high-risk subgroup may be identifiable to rationalize a postoperative surveillance programme.