Presidential address: What would you do if it were your father? Reflections on endovascular abdominal aortic aneurysm repair
2001; Elsevier BV; Volume: 33; Issue: 6 Linguagem: Inglês
10.1067/mva.2001.115374
ISSN1097-6809
Autores Tópico(s)Aortic Disease and Treatment Approaches
ResumoI would like to thank you for the great privilege of serving as the 27th president of the New England Society for Vascular Surgery. Our society, the first regional vascular society in the nation, has a long and proud heritage of accomplishment and contributions to our specialty, and many leaders in our field have emerged from our ranks. The New England Society for Vascular Surgery represents all that is positive and valuable in a regional society. To be elected by you, my friends and colleagues, to carry its banner is the highest honor one could wish for. The chance to present a presidential address represents an unparalleled opportunity to express one's views without constraints of scientific evidence or hard data. However, with this unique occasion comes the difficulty of selecting an appropriate and worthy topic. In making such a choice, one usually becomes a scholar of past presidential addresses and discovers several broad categories of topics. These vary from scientific, historic, or socioeconomic themes to political or even philosophical views of the individual. Although one hopes to say something learned and profound, you discover that there is really no way to select a truly new topic. It is usually recommended to say something meaningful but avoid too much philosophical overtones and to keep it brief without too many slides. The best advice seems to be to make your selection a personal one and talk about something that you know about and are sincerely interested in. It also helps if the topic is controversial and timely, because it is possible your comments may actually add some helpful and potentially beneficial opinions and perspectives. For all of these reasons, I have chosen to direct my remarks towards the subject of endovascular repair of abdominal aortic aneurysm (AAA). I believe it is an important subject and it is certainly a controversial one. To me, it represents both the challenges and opportunities that exist for our specialty as we enter a new millennium. Indeed, the evolution of the treatment of aortic aneurysm offers a fascinating window into the remarkable progress that vascular surgery has made over the last half of the 20th century. It was the best of times, it was the worst of times.Charles Dickens, A Tale of Two Cities As we enter a new millennium, we are truly in a period of dramatic change and epochal transformation. As a youngster, I recall futuristic books such as 1984 by George Orwell or 2001: A Space Odyssey by Arthur C. Clarke. The concepts and images in these works seemed so far off, yet Big Brother and spacecraft Discovery are a reality now. In this current “computer age” and “knowledge and service society” we now live in, few would recognize the world into which one's parents were born. For example, in 1945 more than 30% of all workers lived and worked on farms; today, less that 2% do.1Sheldon GF Y2K at the ACS.Bull Am Coll Surg. 1999; 84: 3-4PubMed Google Scholar The bygone era of the doctor's black bag and glass hypodermic needle has been replaced with computed tomography (CT) scans, magnetic resonance imaging, designer drugs, and high-tech magic bullets. Vascular surgery has not escaped this revolutionary change. Emblematic of our current age of technology, new therapies, largely catheter-based, are challenging our traditional “index” surgical procedures. We've grown comfortable with such traditional open procedures, know how to perform them, and know when they should be done. In this new era, some have said that 40% to 70% of these signature procedures will be replaced.2Veith FJ Presidential address: Charles Darwin and vascular surgery.J Vasc Surg. 1997; 25: 8-18Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar In addition to significantly altering accepted approaches and standard procedures, the new technology crosses practice boundaries and is also the focus of intense entrepreneurial and commercial activity. The impact of technology is change, but with change often come conflict and anxiety.3Veith FJ Presidential address: transluminally placed endovascular stented grafts and their impact on vascular surgery.J Vasc Surg. 1994; 20: 855-860Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar Endovascular AAA repair is currently a focal point for conflict and anxiety that such changes have created in our own specialty. Few topics are more controversial or of more concern to all practitioners. This catheter-based, image-guided technology has the potential to redefine traditional care of one of our specialty's most common and important surgical procedures. As surgeons, we all make daily decisions regarding the best treatment for our patients. We must determine whether operative intervention is indicated, what procedure would be best, and what should be the optimal timing. In reaching such often difficult decisions, we are all familiar with being asked by patients and their families, “What would you do if it were your father?” as if such a statement would encourage us to make a better or more thoughtful recommendation. Therefore, I've decided to relate my observations and opinions on endoluminal AAA repair in this framework. AAA remains an important problem. Approximately 200,000 new cases are diagnosed each year, and 50,000 to 60,000 surgical AAA repairs are performed. Ruptured AAA is responsible for approximately 15,000 deaths in the United States each year, making it the 14th leading cause of death in this country, similar in magnitude to emphysema, renal disease, and homicide.4Holleb AI Vital statistics of the United States, 1984.CA Cancer J Clin. 1987; 37: 6Google Scholar It is clear that we are an aging society. From 1900 to 1996, life expectancy increased approximately 30 years, from less than 50 years to almost 80, a stunning prolongation of life of three decades. With age 65 as the usual definition of an elderly person, by 2020 when current baby boomers come of age, the elderly segment of our society is expected to increase by 35%.5Bureau of the Census Statistical Abstract of the United States US Current population reports.114th ed. US Department of Commerce, Washington1994Google Scholar, 6Stanley JC Barnes RW Ernst CB Hertzer NR Mannick JA Moore WS Vascular surgery in the United States: workforce issues. Report of the Society for Vascular Surgery and the International Society for Cardiovascular Surgery, North American Chapter, Committee on Workforce Issues.J Vasc Surg. 1996; 23: 172-181Abstract Full Text PDF PubMed Scopus (100) Google Scholar The over-85 age group is the fastest growing segment of the population in our country. Indeed, the US Census Bureau estimates that the number of people 100 years of age or older will increase almost 30-fold, to more than 800,000 centenarians by 2050.7Harvard Health Letter. 1999; 25: 1-2Google Scholar It is certain that our patients are getting older, and some extremely old. The impact of this is the certainty of more aneurysms, because abundant data exist to show that the prevalence of AAA and rupture risk increases sharply with advancing age.8Lederle FA Johnson GR Wilson SE Chute EP Littooy FN Bandyk D for the Aneurysm Detection and Management ADAM Veterans Affairs Cooperative Study Group et al.Prevalence and associations of abdominal aortic aneurysm detected through screening.Ann Intern Med. 1997; 126: 441-449Crossref PubMed Scopus (675) Google Scholar, 9Bengtsson H Bergqvist D Ruptured abdominal aortic aneurysm: a population-based study.J Vasc Surg. 1993; 18: 74-80Abstract Full Text Full Text PDF PubMed Scopus (294) Google Scholar One in 10 men older than 80 has some aneurysmal change in his aorta.10Bengtsson H Bergqvist D Ekberg O Janzon L A population based screening of abdominal aortic aneurysms (AAA).Eur J Vasc Surg. 1991; 5: 53-57Abstract Full Text PDF PubMed Scopus (133) Google Scholar Besides aging, other factors must be involved, because the incidence of small AAA has increased almost 30-fold.11Hallett Jr, JW Naessens JM Ballard DJ Early and late outcome of surgical repair for small abdominal aortic aneurysm: a population-based analysis.J Vasc Surg. 1993; 18: 684-691Abstract Full Text Full Text PDF PubMed Scopus (85) Google Scholar Certainly, better diagnosis and more frequent imaging studies are involved, but it appears there has been a true increase in prevalence as well.12Melton LJ Bickerstaff LK Hollier LH Peenen HJ Lie JT Pairolero PC et al.Changing incidence of abdominal aortic aneurysms: a population-based study.Am J Epidemiol. 1984; 120: 379-386PubMed Google Scholar Thus, it is certain that in coming years vascular surgeons are going to deal with more patients with AAA in their practice, many of whom are elderly and high risk. Several estimates indicate a likely increase of 30% to 40% in aneurysmal disease in a vascular division's activities.6Stanley JC Barnes RW Ernst CB Hertzer NR Mannick JA Moore WS Vascular surgery in the United States: workforce issues. Report of the Society for Vascular Surgery and the International Society for Cardiovascular Surgery, North American Chapter, Committee on Workforce Issues.J Vasc Surg. 1996; 23: 172-181Abstract Full Text PDF PubMed Scopus (100) Google Scholar, 13Heikkinen M Salenius JP Auvinen O Projected workload for a vascular service in 2020.Eur J Vasc Endovasc Surg. 2000; 19: 351-355Abstract Full Text PDF PubMed Scopus (23) Google Scholar It is also apparent to me that we are not currently doing as well as we often think in treating patients with AAA. Although elective mortality rates of only 1% to 5% are reported in many high-volume institutional-based studies,14Ernst CB Abdominal aortic aneurysms.N Engl J Med. 1993; 328: 1167-1172Crossref PubMed Scopus (645) Google Scholar numerous population-based reports that are more likely representative of the “real world” show mortality rates in the 5% to 10% range even in contemporary practice.15Katz DJ Stanley JC Zelenock GB Operative mortality rates for intact and ruptured aortic aneurysms in Michigan: an eleven-year statewide experience.J Vasc Surg. 1994; 19: 804-817Abstract Full Text Full Text PDF PubMed Scopus (323) Google Scholar, 16Kazmiers A Jacobs L Perkins A Lindenauer SM Bates E Abdominal aortic aneurysm repair in Veterans Affairs medical centers.J Vasc Surg. 1996; 23: 191-200Abstract Full Text Full Text PDF PubMed Scopus (145) Google Scholar, 17The UK Small Aneurysm Trial Participants Mortality results for randomized controlled trial of early elective surgery or ultrasonographic surveillance for small abdominal aortic aneurysm.Lancet. 1998; 352: 1649-1655Abstract Full Text Full Text PDF PubMed Scopus (979) Google Scholar, 18Lawrence PF Gozak C Bhirangi L Jones B Bhirangi K Oderich G et al.The epidemiology of surgically repaired aneurysms in the United States.J Vasc Surg. 1999; 30: 632-640Abstract Full Text Full Text PDF PubMed Scopus (157) Google Scholar Significant systemic complications occur in at least 15% to 30% of patients,19Johnston KW Multicenter prospective study of nonruptured abdominal aortic aneurysm, part II: variables predicting morbidity and mortality.J Vasc Surg. 1989; 9: 437-447PubMed Scopus (383) Google Scholar, 20Cambria RP Brewster DC Abbott WM L'Italien GJ Megerman JJ LaMuraglia GM et al.The impact of selective use of dipyridamole thallium scans and surgical factors on the current morbidity of aortic surgery.J Vasc Surg. 1992; 15: 43-50Abstract Full Text Full Text PDF PubMed Scopus (74) Google Scholar, 21Steyerberg EW Kievit J de Mol Van Otterloo JCA van Bochel JH Eijkemans MJC Habbema JDF Perioperative mortality of elective abdominal aortic aneurysm surgery: a clinical prediction rule based on literature and individual patient data.Arch Intern Med. 1995; 155: 1998-2004Crossref PubMed Scopus (172) Google Scholar and morbidity and mortality rates are recognized to substantially increase in elderly patients or in those with significant pulmonary or renal comorbidities.19Johnston KW Multicenter prospective study of nonruptured abdominal aortic aneurysm, part II: variables predicting morbidity and mortality.J Vasc Surg. 1989; 9: 437-447PubMed Scopus (383) Google Scholar, 22Dardik A Lin JW Gordan TA Williams GM Perler BA Results of elective abdominal aortic aneurysm repair in the 1990s: a population-based analysis of 2335 cases.J Vasc Surg. 1999; 30: 985-995Abstract Full Text Full Text PDF PubMed Scopus (206) Google Scholar Recovery commonly takes several months, and some elderly individuals never quite regain their preoperative baseline status. In addition, many high-risk patients are currently denied operative repair because they are considered unlikely to survive the procedure. Finally, it is well documented that we are making little progress in improving results of ruptured AAA. Despite more frequent elective operations, the incidence and poor outcome of ruptured AAA have remained virtually unchanged over the past 20 years.23Heller JA Arons R Weinberg A Krishnasastry KV Lyon RT Deitch JS et al.Two decades of abdominal aortic aneurysm repair: have we made any progress?.J Vasc Surg. 2000; 32: 1091-1100Abstract Full Text Full Text PDF PubMed Scopus (202) Google Scholar Therefore, the possibility of a less invasive method of treatment that might reduce risk, provide other possible patient benefits including quicker recovery, and extend the chance of successful repair to a greater number of patients has tremendous appeal to patients and physicians alike. If my father had an AAA, the first thing I would tell him would be to seriously consider endovascular repair. It's a real treatment possibility, and not a fad likely to disappear like laser angioplasty. The farther backward you can look, the farther forward you are likely to see. Winston Churchill 24Smith III, RB The foundations of modern aortic surgery.J Vasc Surg. 1998; 27: 7-15Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar The tides of technology are strong, and lessons of the past slip quickly behind us.25Hallett Jr, JW Presidential address: back to the future of vascular surgery—why certain procedures become obsolete.J Vasc Surg. 1997; 25: 791-795Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar The evolution of AAA treatment is both fascinating and potentially instructive. Although recognized in Egyptian mummies and described by other early physicians, the actual treatment of aneurysms was not attempted until many centuries later. The focus of early intervention was ligation or banding, but results were usually poor because of the failure to totally exclude the AAA and prevent its rupture resulting from insecure obliteration of proximal or distal flow, collateral blood flow into the sac, or erosion of bands or ligatures through the aortic neck with resultant fatal hemorrhage.24Smith III, RB The foundations of modern aortic surgery.J Vasc Surg. 1998; 27: 7-15Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar Does this sound at all familiar to some of the current potential difficulties and shortcomings of endovascular repair? Other early efforts aimed at limiting AAA expansion and rupture included wrapping the aneurysm with materials such as cellophane, thereby hoping to limit growth or disruption by both mechanical restraint and an intense induced perianeurysmal inflammatory response and subsequent fibrosis. Perhaps the best known patient treated in this fashion was Albert Einstein, then the world's most famous and outstanding scientist, who underwent cellophane wrapping for a “large” and possibly symptomatic AAA in 1948, just before the dawn of true AAA graft repair. Einstein would survive 6 ½ years before succumbing in 1955 to fatal AAA rupture at age 76, rejecting recommended urgent surgical treatment at that time. Einstein said, “I want to go when I want. It is tasteless to prolong life artificially, I have done my share, it is time to go. I will do it elegantly.”26Cohen JR Graver LM The ruptured abdominal aortic aneurysm of Albert Einstein.Surg Gynecol Obstet. 1990; 170: 455-458PubMed Google Scholar Was the better than anticipated 6 ½-year survival after his wrapping procedure just good luck, or did the treatment itself favorably modify the natural history of that aneurysm? Should his procedure be judged a failure, or in fact, was it in many ways quite successful? Again, there are similarities to dilemmas now encountered in evaluating the place of stent graft repair. The possible advantages of working “within” the vascular system itself were recognized early. The attempted treatment of aneurysm with endoluminal wiring was practiced for many years.27Finney JMT The wiring of otherwise inoperable aneurysms.Ann Surg. 1912; 55: 661-681Crossref PubMed Google Scholar, 28Blakemore AH King BG Electrothermic coagulation of aortic aneurysms.JAMA. 1938; 111: 1821-1827Crossref Scopus (35) Google Scholar Although generally ineffective in this regard, it is certainly a prelude to intraluminal coiling and embolization of aneurysmal vessels in use today. Certainly the endoaneurysmorrhaphy principles of Matas,29Matas R An operation for the radical cure of aneurysm based upon arteriorrhaphy.Ann Surg. 1903; 37: 161-196PubMed Google Scholar culminating in the endoaneurysmal technique of graft implantation first described by Creech,30Creech O Endo-aneurysmorrhaphy: treatment of aortic aneurysms.Ann Surg. 1966; 164: 935-946Crossref PubMed Scopus (170) Google Scholar are commonly applied as standard practice today. The desire to reduce morbidity and mortality by working endoluminally led to the first catheter-based treatment of vascular disease by Fogarty in 1963 and ultimately to the initial catheter-based treatments of AAA with transfemoral endograft repair.31Dotter C Transluminally-placed coilspring endarterial tube grafts: long-term patency in a canine popliteal artery.Invest Radiol. 1969; 4: 329-332Crossref PubMed Scopus (532) Google Scholar, 32Parodi JC Palmaz JC Barone HD Transfemoral intraluminal graft implantation for abdominal aortic aneurysm.Ann Vasc Surg. 1991; 5: 491-499Abstract Full Text PDF PubMed Scopus (2796) Google Scholar Few would disagree that progress in modern aortic surgery would not have been possible without the development of clinically applicable prosthetic arterial substitutes.33Smith RB. Arthur B. Voorhees Jr, pioneer vascular surgeon.J Vasc Surg. 1993; 18: 341-348Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar Rigid tubes had been tried to replace diseased blood vessels, but these failed early because of thrombosis or erosion.34Hufnagel CA. Permanent intubation of the thoracic aorta. Arch Surg 19470;54:382-9.Google Scholar Homograft insertion represented an early breakthrough, but these conduits were soon noted to undergo significant biologic degeneration and have additional problems of procurement and availability. The era of modern vascular surgery began with Voorhees and his development of Dacron grafts in the early 1950s. Like Fogarty, Voorhees was a surgical resident when he began his innovative seminal work. Although his first efforts at fashioning an arterial conduit in the animal laboratory, created at first on his wife's sewing machine from a silk handkerchief, and later using Vinyon-N, a fabric used for making spinnaker sails, were only partially successful, continued work by him and his colleagues ultimately led to development of reliable prosthetic grafts as we now know them.35Voorhees Jr, AB Jaretski A.IV Blakemore AH The use of tubes constructed from Vinyon-”n” cloth in bridging arterial defects.Ann Surg. 1952; 135: 332-336Crossref PubMed Scopus (299) Google Scholar Is there a lesson to be learned here? Perhaps one should not condemn or abandon a new concept of treatment or a newly developed device simply because of problems and failures of initial prototypes and early first-generation versions. It is the patient rather than the case which requires treatment.Robert Tuttle Morris, Doctors Versus Folks At the heart of the current uncertainty about the proper role of endovascular AAA repair is the debate regarding what should constitute appropriate and meaningful outcome criteria. In other words, how should we define success? Endoluminal repair is criticized mainly for two perceived shortcomings: endoleak and inferior durability. Failure to completely exclude the AAA from the circulation, as determined with postimplant radiologic studies, has been termed endoleak .36White GH Yu W May J Chaufour X Stephen MS Endoleak as a complication of endoluminal grafting of abdominal aortic aneurysms: classification, incidence, diagnosis, and management.J Endovasc Surg. 1997; 4: 152-168Crossref PubMed Scopus (658) Google Scholar To be sure, endoleaks are not infrequent and are reported in 15% to 52% of early postimplant CT scans in various series.37Moore WS Rutherford RB for the EVT Investigators Transfemoral endovascular repair of abdominal aortic aneurysm: results of the North American EVT Phase I Trial.J Vasc Surg. 1996; 23: 543-553Abstract Full Text PDF PubMed Scopus (336) Google Scholar, 38Blum U Voshage G Lammer J Beyerdorf F Tollner D Kretschmer G et al.Endoluminal stent grafts for infrarenal abdominal aneurysms.N Engl J Med. 1997; 336: 13-20Crossref PubMed Scopus (557) Google Scholar, 39Wain RA Marin ML Ohki T Sanchez LA Lyon RT Rozenblit A et al.Endoleaks after endovascular graft treatment of aortic aneurysms: classification, risk factors, and outcome.J Vasc Surg. 1998; 27: 69-80Abstract Full Text Full Text PDF PubMed Scopus (183) Google Scholar, 40Cuypers P Buth J Harris P Gevers E Lahey R Realistic expectations for patients with stent-graft treatment of abdominal aortic aneurysms: results of a European multicentre registry.Eur J Vasc Endovasc Surg. 1999; 17: 507-516Abstract Full Text PDF PubMed Scopus (135) Google Scholar, 41Zarins CK White RA Hodgson KJ Schwarten D Fogarty TJ for the AneuRx Clinical Investigators Endoleak as a predictor of outcome following endovascular aneurysm repair: AneuRx multicenter clinical trial.J Vasc Surg. 2000; 32: 90-107Abstract Full Text Full Text PDF PubMed Scopus (253) Google Scholar In a meta-analysis of 23 publications in which 1118 patients are described with successful implantation of AAA endografts, Schurink et al42Schurink GWH Aarts NJM van Bockel JH Endoleak after stent graft treatment of abdominal aortic aneurysm: a meta-analysis of clinical studies.Br J Surg. 1999; 86: 581-587Crossref PubMed Scopus (138) Google Scholar determined an average endoleak rate of 24%. It is commonly believed that persistent endoleak represents a clinical failure of the procedure, but I'm not certain this is valid. A second criticism of endoluminal repair is its potentially inferior durability as compared with conventional open surgery. Such concerns have been voiced with increasing frequency within the recent time period as midterm experience has accumulated and documented instances of device structural failure, migration, late endoleaks, limb thrombosis, and other problems including rupture.43Harris PL The highs and lows of endovascular aneurysm repair: the first two years of the Eurostar Registry.Ann R Coll Surg Engl. 1999; 81: 161-165PubMed Google Scholar, 44Maleux G Rousseau H Otal P Colombier D Glock Y Joffre F Modular component separation and reperfusion of abdominal aortic aneurysm sac after endovascular repair of abdominal aortic aneurysm: a case report.J Vasc Surg. 1998; 28: 349-352Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar, 45Krohg-Sorensen K Brekke M Drolsum A Kvernebo K Periprostehtic leak and rupture after endovascular repair of abdominal aortic aneurysm: the significance of device design for long-term results.J Vasc Surg. 1999; 29: 1152-1158Abstract Full Text Full Text PDF PubMed Scopus (66) Google Scholar, 46Beebe HG Cronenwett JL Katzen BT Brewster DC Green RM Results of an aortic endograft trial: impact of device failure beyond 12 months.J Vasc Surg. 2001; 33: 555-563Abstract Full Text PDF Scopus (176) Google Scholar, 47Lumsden AB Allen RC Chaikof EL Resnikoff M Moritz MW Gerhard H et al.Delayed rupture of aortic aneurysms following endovascular stent grafting.Am J Surg. 1995; 170: 174-178Abstract Full Text PDF PubMed Scopus (164) Google Scholar, 48Alimi YS Chakfe N Rivoal E Slimone KK Valerio N Riepe G et al.Rupture of an abdominal aortic aneurysm after endovascular stent graft placement and aneurysm size reduction.J Vasc Surg. 1998; 28: 178-183Abstract Full Text Full Text PDF PubMed Scopus (147) Google Scholar, 49Torsello GB Klenk E Kasprzak B Umscheid T Rupture of abdominal aortic aneurysm previously treated by endovascular stent graft.J Vasc Surg. 1998; 28: 184-187Abstract Full Text Full Text PDF PubMed Scopus (156) Google Scholar, 50Zarins CK White RA Fogarty TJ Aneurysm rupture after endovascular repair using the AneuRx stent graft.J Vasc Surg. 2000; 31: 960-970Abstract Full Text Full Text PDF PubMed Scopus (209) Google Scholar However, further experience has also clearly showed that many, if not most, such difficulties except rupture may be successfully treated with secondary catheter-based interventions, and that open operations are usually unnecessary.41Zarins CK White RA Hodgson KJ Schwarten D Fogarty TJ for the AneuRx Clinical Investigators Endoleak as a predictor of outcome following endovascular aneurysm repair: AneuRx multicenter clinical trial.J Vasc Surg. 2000; 32: 90-107Abstract Full Text Full Text PDF PubMed Scopus (253) Google Scholar, 51May J White GH Waugh R Petrasek P Chaufour X Arulchelvan M et al.Life-table analysis of primary and assisted success following endoluminal repair of abdominal aortic aneurysms: the role of supplementary endovascular intervention in improving outcome.Eur J Vasc Endovasc Surg. 2000; 19: 648-655Abstract Full Text PDF PubMed Scopus (53) Google Scholar Are such problems, therefore, appropriate justification for condemnation of the method? I would suggest to my father that he consider somewhat different and more pragmatic outcome criteria for success (Table I) than those commonly proposed.52Ahn SS Rutherford RB Johnston KW May J Veith FJ Baker JD et al.Reporting standards for infrarenal endovascular abdominal aortic aneurysm repair.J Vasc Surg. 1997; 25: 405-410Abstract Full Text Full Text PDF PubMed Scopus (197) Google ScholarTable ICriteria for clinical “success”No perioperative mortalityNo AAA ruptureNo AAA growth (≥ 5 mm)No conversions/explant Open table in a new tab Certainly no patient wishes to not survive the procedure, so mortality risk is a legitimate concern. I would naturally focus attention on what is, after all, the goal of any treatment for AAA: to prevent aneurysm rupture. Because of the well-established relationship of size and rupture risk, limiting AAA growth is a natural corollary of this goal. Finally, a patient undergoing endovascular repair would naturally wish to avoid the need for conversion to open repair, either acutely or during the later follow-up interval, especially in view of the increased morbidity and mortality of conversions documented in many reports.53May J White GH Yu W Waugh R Stephen M Sieunarine K et al.Conversion from endoluminal to open repair of abdominal aortic aneurysms: a hazardous procedure.Eur J Vasc Endovasc Surg. 1997; 14: 4-11Abstract Full Text PDF PubMed Scopus (104) Google Scholar, 54Jacobowitz GR Lee AM Riles TS Immediate and late explanation of endovascular aortic grafts: EndoVascular Technologies experience.J Vasc Surg. 1999; 29: 309-316Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar Notably absent in these objectives is endoleak status, which in my mind is generally overemphasized in evaluating the efficacy of endoluminal repair. Although endoleaks may frequently be correlated with subsequent AAA expansion and rupture risk, this is often an uncertain relationship. Some series have shown that a substantial number of AAAs stay unchanged in maximal diameter, or even decrease in size, despite demonstrated endoleak.41Zarins CK White RA Hodgson KJ Schwarten D Fogarty TJ for the AneuRx Clinical Investigators Endoleak as a predictor of outcome following endovascular aneurysm repair: AneuRx multicenter clinical trial.J Vasc Surg. 2000; 32: 90-107Abstract Full Text Full Text PDF PubMed Scopus (253) Google Scholar, 55Wolf YG Hill BB Rubin GD Fogarty TJ Zarins CK Rate of change in abdominal aortic aneurysm diameter after endovascular repair.J Vasc Surg. 2000; 32: 108-115Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar, 56Deaton DH Results of a multi-centre trial of the EVT endovascular grafting system.J Endovasc Surg. 1999; 6: 84-85Google Scholar, 57Franco TJ Zajko AB Federle MP Makaroun MS Endovascular repair of abdominal aortic aneurysms with the Ancure endograft: CT follow-up of perigraft flow and aneurysm size at 6 mos.J Vasc Interv Radiol. 2000; 11: 429-435Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar, 58Schunn CD Krauss M Heilberger P Ritter W Raithel D Aortic aneurysm size and graft behavior after endovascular stent-grafting: experiences and observations over 3 years.J Endovasc Ther. 2000; 7: 167-176Crossref PubMed Google Scholar, 59Gilling-Smith GL Cuypers P Buth J Harris PL for the Eurostar CollaboratorsThe significance of endoleaks after endovascular aneurysm repair: results of a large European multicentre study.J Endovasc Surg. 1998; 5: I-12Google Scholar Type II (branch) endoleaks, by far the most common variety in all series, are thought by some investigators to not result in AAA expansion or rupture in most cases.60Resch T Ivancev K Lindh M Nyman U Brunkwall J Malina M et al.Persistent collateral perfusion of the abdominal aneurysm after endovascular repair does not lead to progressive change in aneurysm diameter.J Vasc Surg. 1998; 28: 242-249Abstract Full Text Full Text PDF PubMed Scopus (144) Google Scholar, 61Jacobo
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