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Endovascular Aortic Aneurysm Repair

Originally developed for patients with abdominal aortic aneurysm for patients considered to have physical problems that made them ineligible for surgery.

Each year, 40,000 patients in the United States undergo elective procedures to repair abdominal aortic aneurysms.

These procedures result in about 1250 perioperative deaths ― more than for any other general or vascular surgical procedure, with the exception of colectomy.

Endovascular repair is a less invasive method than traditional open repair and trials have shown that endovascular repair reduces perioperative mortality,

Applicability to infrarenal abdominal aortic aneurysms exceeds 50%.

Rupture rate about 1% per year after endovascular repair.

Need for conversion to open graft repair is approximately 2% of patients per year.

Hospitalization about 3.4 days.

30-day mortality ranges from 0.7% in low-risk populations to 15.7% in high-risk patients.

Morbidity rates reported as 12% for endovascular repair and 23% for open surgery.

Incidence or rupture is 0.4% over 4.5 years.

Exclusion of the aneurysm sac ranges from 66-87% compared to open surgical technique with nearly 100% exclusion.

United Kingdom Endovascular Aneurysm Repair 2 (EVAR2) indicated no improvement on total or aneurysm related mortality in up to 4 years of follow-up, and an unexpected mortality rate of 9% was a significant factor in the negative result.

In the above study the 4 year mortality was 68%.

In the EVAR2 study the rate of rupture of large untreated aneurysms was lower than anticipated, (9 ruptures per 100 person-years).

EVAR2 study review at 8 years indicated an operative mortality of 7.3% at 30 days.

EVAR2 study revealed the control group, no intervention, had a overall rate of aneurysm rupture rate of 12.4% per 100-persons years.

EVAR2 study revelaed aneurysm related mortlaity lower in the endovasclar repair group compared to control patients without intervention, but it did not result in any benefit in total mortality.

EVAR2 study a total of 48% of patients who survived endovascular repair had grafted related complications and 27% required reintervention within the first 6 years.

In the United Kingdom Endovascular Aneurysm Repair 1 (EVAR 1) trial and the Dutch Randomized Endovascular Aneurysm Management (DREAM) trial, this advantage was lost within 2 years owing to excess late deaths in the endovascular-repair groups.

In the Open versus Endovascular Repair (OVER) Veterans Affairs Cooperative Study, excess late deaths were not observed in the endovascular-repair group at 2 years.

Long-Term Comparison of Endovascular and Open Repair of Abdominal Aortic Aneurysm found perioperative mortality was lower in the endovascular-repair group than in the open-repair group, but the difference in mortality between the two groups was no longer significant at 2 years (Lederle FA et al).

In this long-term, multicenter, randomized trial involving patients with abdominal aortic aneurysm, there was no significant difference in the primary outcome of long-term all-cause mortality between the endovascular-repair group and the open-repair group.

The perioperative survival advantage with endovascular repair was sustained for several years, after which there was no significant difference between the two groups.

Endovascular repair led to improved long-term survival among patients younger than 70 years of age, but among older patients it tended to reduce survival.

Aneurysm rupture after repair was uncommon but occurred only in the endovascular-repair group, resulting in a significant between-group difference.

We found no significant difference between the two groups with respect to number of secondary therapeutic procedures, number of postrepair hospitalizations, quality of life, or erectile dysfunction.

The short-term benefit of endovascular repair was most pronounced among the patients who were most fit,1and long-term complications and reinterventions after endovascular repair were more common among older patients.

Late rupture occurred only in the endovascular-repair group, and that the rates of secondary therapeutic procedures were similar after endovascular repair and open repair,

Endovascular repair is an acceptable alternative to open repair even when judged in terms of long-term survival.

Late rupture remains a concern and that endovascular repair does not yet offer a long-term advantage over open repair, particularly among older patients.

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