EVAR Treatment of rAAA: A Major Advance

Dr. Frank Veith and his associates set out to improve the management of patients presenting with a ruptured abdominal aortic aneurysm (rAAA) in 1994, a short 2 years following the performance of the first endovascular repair (EVAR) in the United States (2002). It was a somewhat daring but most appropriate undertaking given the reality of continued high mortality from rAAA, despite the many significant advances in operative techniques and peri-operative care of the past 20 years. This work has spanned 15 years, and the quest continues. It is an almost sure thing that EVAR offers patients a much better outlook, but the issue is not without controversy, as a few groups around the world have reported no survival improvement when compared with the historical results of open repair (OR). Such questions and uncertainty have prompted some to voice the need for a randomized trial that compares standard OR to EVAR in the management of patients with a rAAA. And it may well be that one or more such studies will see the light of day in the near future, despite strong objections that would liken this situation to the “parachute scenario,” where the benefit of the therapy (like wearing a parachute vs. not when jumping out of a flying airplane) is immediately obvious and self-evident. Whether or not such clinical studies are performed, EVAR has already evolved as a major advancement in the treatment of rAAA. Additionally, several important breakthrough developments have evolved along the way, especially hypotensive hemostasis and balloon occlusion for proximal aortic control (when necessary). They represent major departures from time-honored classic surgical principles and reflect a sharpened understanding in the area of critical things to do and not do to enhance the patient’s chance of survival. But implementation of a program where EVAR can be offered to most patients presenting with rAAA will not be easy or even possible everywhere. The following requirements are often cited as potential limitations: availability of an experienced and highly skilled team of operators, a relatively large number of rAAA cases managed each year, and the ability to offer such service on a “24/7 basis.” It is clear that only a handful of hospitals in each region can (and perhaps, should) embark on such a program. I am sure VDM readers will find the article by Veith and Cayne¹ in this month’s issue both interesting and provocative. Abdominal aortic aneurysms represent a most important disease for all vascular specialists, and for the whole of cardiovascular medicine. Furthermore, its impact on society at-large cannot be ignored, as it claims nearly 20,000 lives each year in the United States alone. The vast majority of these relate to rupture of the aneurysm.

Reference

1. Veith FJ and Cayne N. Endovascular repair (EVAR) for ruptured abdominal aortic aneurysms: Why the results vary. Vascular Disease Management 2009;6:165–170.

Vascular Surgery and Endovascular Intervention; Union Memorial Hospital/ MedStar Health, Baltimore, Maryland frank.criado@medstar.net