Endovascular Abdominal Aortic Aneurysm Repair - Patient Selection and Long-term Outcome Expectations - Current Challenges in 2013

Endografts for repair of abdominal aortic aneurysm were first reported in the late 1980s and commercially available grafts were developed rapidly during the 1990s. This prompted a head-to-head comparison of the new, less invasive, endovascular technology with the existing gold standard of open repair. The first and largest randomised trial of open versus endovascular repair for large aneurysms started in the UK in 1999. Other trials comparing open and endovascular repair followed in the Netherlands, France and the US. Only the UK trial has reported long-term follow-up to 10 years. This has shown no statistically significant difference in long-term survival after open or endovascular repair. Aneurysm-related mortality curves converged at six years, which is described as endovascular aortic repair (EVAR) 'catch up' on open repair. It appears that this convergence is probably largely attributable to secondary sac rupture after endovascular repair, which is fatal in about two-thirds of cases. At this point, we have reached a crossroads and only longer-term follow-up data can provide the vital answer to the outcome of endovascular repair in the long run. This article gives a brief overview of the development and the current evidence of endovascular aortic repair and discusses the most important factors that are leading the way to the future of this technology.