LAUSR

The endovascular aneurysm repair (EVAR) trials showed conclusively the significant initial benefit of EVAR compared to standard open surgical repair, in particular better 30 day mortality of 1.6 vs. 4.7% and lower major cardiac, respiratory, haemorrhagic and renal complications. These results were replicated by several other studies in different healthcare systems including the OVER, DREAM and ACE trials. This of course was not surprising given the less invasive nature of the new procedure [1]. Although the costs of EVAR were shown to be higher, with some additional unique complications such as endoleaks, EVAR became established as a viable alternative for the treatment of patients with unruptured abdominal aortic aneurysms (AAA) and was recognised by national institute for health and care excellence (NICE) in the UK. Industry partners listened to clinician’s needs and devices became easier to use and more accurate to deploy. With increasing confidence in EVAR, many operators started placing stentgrafts in virtually all patients including those outside the instructions for use (IFU) with increasingly difficult anatomy, in some centres achieving a[ 90% EVAR rate. Industry responded to these demands in an effort to make devices applicable to an ever wider subset of patients and with that has come a reduction in profile and evolution of the original design concept. Newer alloys such as Nitinol, repositionable devices, shorter Z stents, ring or spiral type stents and wider fabric gaps have been developed to increase conformability and flexibility. This focus was initially directed at wider applicability and backed by good early outcomes, but durability was not considered with few studies reporting outcomes beyond 3 years. Amid the enthusiasm from both clinicians and patients, there were some early signs of possible trouble ahead. The Eurostar registry reported poorer outcomes and increased re-interventions in patients with large sacs and larger diameter proximal necks. Others went further with Jack Collin and John Murie entitling a 2002 editorial in the British Journal of Surgery, ‘‘Endovascular treatment of abdominal aortic aneurysm: A failed experiment’’. This early wakeup call highlighted the failure of EVAR to significantly reduce the overall rupture risk in the population treated, the failure rate of devices and the higher costs. However, at the time, there was no hard evidence to back this warning shot across EVAR’s bows and the general enthusiasm for the procedure won through. However, the long term follow-up data from some of the original EVAR trials have started to show some disturbing results [2–4]. The 3% early EVAR survival benefit is lost by 4 years, and between 8 and 14 years there is a survival benefit to open surgery. This is as a result of an increase in both aneurysm related and overall mortality in the EVAR group. Late aortic ruptures account for the former and concerns regarding an increase in abdominal malignancies due at least in part to increased radiation exposure caused by numerous follow-up CT-examinations may have contributed to the latter. In