Selection of Patients with Aortic Aneurysms for Open Surgical or Endovascular Repair

Open Repair of Abdominal Aortic Aneurysm

Improvements in patient selection, preoperative preparation, anesthesia, surgical technique, and postoperative care have made open AAA repair a safe surgical option for most patients.

Reported morbidity following open AAA repair varies widely and increases with age. Early postoperative complications are related to underlying comorbidities and include respiratory (8%–16%), major cardiac (3%–8%), renal (2%–10%), visceral ischemic (1%–3%), and sexual (erectile dysfunction and retrograde ejaculation) (≤85%) complications. Late graft-related complications are uncommon but can be associated with mortality and include anastomotic pseudoaneurysm (1%–3% proximal, 8%–9% distal), graft infection (0.3%–1.3%), aortoenteric fistula (0.3%–1.6%), limb thrombosis (1.6%–5.3%) and aneurysmal expansion of the residual aorta (5%). Nonvascular late complications also occur including ventral hernia, small bowel obstruction, and ischemic colitis. Moreover, it has recently been recognized that the incidence of these complications is relatively high. Mortality for open repair has remained relatively stable since the 1990s, with 30-day mortalities of less than 3% at centers of excellence and 4% to 6% when large data sets are queried.

Endovascular Aneurysm Repair

Since the turn of the century, EVAR devices have continued to improve. This poses a significant problem when attempting to assess the long-term outcomes of technically laden surgical interventions. Even the most recently reported long-term studies of EVAR evaluate grafts that are a decade old. The indications for EVAR have also evolved and have become less constrained. Initially, grafts were implanted only in patients with infrarenal necks less than 28 mm in diameter and greater than 15 mm in length as well as through large and nondiseased iliac vessels. However, currently grafts are placed in patients with short and large-diameter necks and also in patients with significant iliac disease. Thus, from an anatomic standpoint, the scope of patients for whom EVAR is an option has varied widely.

The improved early outcomes of EVAR have made it a desirable option in treating AAAs. EVAR does not routinely require general anesthesia or postoperative ICU admission. The surgical exposure is limited to the femoral arteries and can be totally percutaneous. Laparotomy and aortic cross clamping are avoided, with the attendant physiologic stress, blood loss, and fluid shifts. Hospital stays are shortened compared to those for open repair, and time to full recovery following EVAR is significantly shortened. Thirty-day mortalities following EVAR have improved over time, and recently reported mortalities from both prospective trials and larger data sets are less than 1%. Although there is significant early advantage to EVAR, there are a plethora of late complications including endoleak, graft migration, limb occlusion, and rupture, all of which mandate lifelong monitoring of these patients.

Open Versus Endovascular Aneurysm Repair: The Data

Over the years, hundreds of studies have been published reporting outcomes of open and endovascular aneurysm repair. However, only recently several long-term randomized, comparative trials have been reported. Before the publication of these studies, there was significant concern that late complications of EVAR would lead to substantial late mortality and perhaps long-term outcomes that are unfavorable compared to those of open repair. A summary of the findings of the most significant of these recent reports follows and is shown in Table 1 .