Conclusions: With low morbidity and mortality, EVAR is a safe technique for the treatment of AAA in patients with concomitantmalignancy and could be considered as an alternative to OR. ( J Vasc Surg 2007;46:16-23.)
Cross-sectional imaging and, in particular, computed tomography (CT) scanning is increasingly being used in the preoperative investigations of patients for a variety of pa- thologies, including cancer and abdominalaorticaneurysm (AAA), and is likely to increase the proportion of patients in whom the two conditions are found to coexist. 1 Although the true incidence is difficult to establish, it has been reported to be as high as 13.4%. 2-4 These patients present a therapeutic dilemma, and their management is controver- sial. 5-7 In those fit to undergo major surgery, one of three strategies might be adopted: (1) to repair the aneurysm first and resect the malignancy later, (2) to treat the malignancy first and repair the aneurysm later, or (3) to undertake both procedures under the same anesthesia.
necessitating an axillobifemoral bypass with excision of graft in one and femoroefemoral crossover and partial excision of a bifurcated graft in the other.
Univariate and multivariable logistic regression. When analyzing EVAR and OSR groups together ( Table III ), the odds of 30-day mortality in the OSR patients was 2.48 times the odds in the EVAR group (95% conﬁdence interval [CI], 1.48-4.18; P ¼ .001). Other signiﬁcant predictors of 30-day mortality included age (odds ratio [OR], 1.05 per year; 95% CI ¼ 1.02-1.07; P ¼ .001), EBL (OR, 1.16 per liter; 95% CI, 1.02-1.32; P ¼ .02), and maximum aneurysm diameter at presentation (OR, 1.45 per cm; 95% CI, 1.23-1.71; P < .001). Compared with male gender, female gender (OR, 1.22; 95% CI, 0.73-2.06; P ¼ .44) was not a signiﬁcant predictor of early mortality. The only other risk factors that signiﬁcantly predicted survival on univariate analysis were a documented history of hypertension (OR, 0.3; 95% CI, 0.18-0.50; P < .001) and smoking (OR, 0.47; 95% CI, 0.24-0.93; P ¼ .03). When all variables were considered together in a multiple variable logistic model, OSR, age, aneurysm size, and hypertension were signiﬁcantly associated with 30-day mortality. When including the effects of age, aneurysm size, and hypertension, odds of 30-day mortality increased by a factor of 2.34 (95% CI, 1.16-4.70) with OSR relative to EVAR.
from 60 min to 255 min, with the average duration of 132 min, while the classic repair lasted from 90 min to 345 min, with the average duration of 151 min. Table 1 reports the baseline characteristics for all patients undergoing AAA repair. Compared to patients undergoing elective openrepair, the group of patients undergoing elective endovascular treat- ment was characterized by a decidedly higher ratio of patients with significant comorbidities. Cardiac, pulmonary, renal and CNS diseases, as well as dia- betes, were more common in the EVAR group. No differences were observed between EVAR and OR groups regarding the incidence of hypertension (Table 2). One hundred fifteen patients in the open surgery group met the high-risk criteria. Thirty- -day mortality rates in patients treated in the elec- tive setting were 1.5% (4 out of 275 patients) for endovascular method and 4.0% (30 out of 743 pa- tients) for the open method. There were 9 deaths (7.8%) in the group of 115 patients meeting the high-risk criteria and managed by elective openrepair (Table 5). In our study cohort, no differenc- es were observed in death causes in EVAR and OR groups. Four deaths in EVAR group were the re- sults of: circulatory failure and/or myocardial in- farction (3 patients) and acute renal failure (1 pa- tient). Most common causes of death within 30 days after the procedure in the OR group were circula- tory failure with or without myocardial infarction (15 patients), pulmonary embolism and stroke (4 and 3 patients, respectively). Deaths occurring > 30 days after procedures for treated patients for EVAR vs. OR were 8.7% vs. 15.7% (Table 5). Table 1. Baseline characteristics for 1018 patients under- going surgical treatment for abdominalaorticaneurysm during study period
of treatment, and no difference in mortality was found in the postoperative period (30 days) among those who have received versusopenrepair (EVAR 21% x 25%) (Reimerink et al., 2013). It has been suggested that the anatomical suitability for EVAR related to a long-necked aneurysm, can confer a survival advantage, even in patients treated by conventional surgery (IMPROVE Trial Investigators, 2014). Immediate treatment of the patients with rupture, a multicenter study (IMPROVE) held in the United Kingdom and in Canada, sought to determine the optimal management of AAA means roto using a drawing of "reality" (IMPROVE Trial Investigators, 2014). The study randomly distributed 613 patients for which there was a suspected ruptured AAA based on history or clinical examination, but before the final image to open correction surgery or EVAR. Patients assigned to a particular group were designated treatment; due to the death before repair or establishment of an alternative diagnosis, the researchers chose to change the type of treatment or patients have not undergone any therapeutic procedure (IMPROVE Trial Investigators, 2014). No difference in postoperative mortality was observed among selected groups. In a pre-specified subgroup analysis, the perioperative mortality was significantly lower for women assigned to the EVAR in comparison with women designated for openrepair (37 x 57%), but this difference was not observed among men. Patients referred for EVAR, received hospital earlier compared to those undergoing conventional surgery (94 x 77%) (IMPROVE Trial Investigators, 2014). The mortality in patients who underwent EVAR, was 25%, compared to 38% of those who underwent open fix (IMPROVE Trial Investigators, 2014). IMPROVE study shows that patients with suspected, but no evidence of ruptured AAA, the opensurgical or endovascular are equally valid (Antoniou et al., 2013).
Research in context
Evidence before this study
We searched MEDLINE and Embase on June 7, 2016, for all articles published from Jan 1, 2006, to May 31, 2016, using search terms “15 year follow up of EVAR for intact abdominalaorticaneurysm”, “long-term elective repair”, “abdominalaorticaneurysm”, “minimally invasive surgery”, “vascular surgical procedures”, endovascular surgery”, and “open surgery”. Three principal randomised controlled trials for abdominalaorticaneurysm have shown marked beneﬁ ts of endovascularaneurysmrepair (EVAR) for 30-day mortality, but total mortality beneﬁ t was lost in these trials after 2 years (EVAR trial 1), 1–2 years (DREAM), and 5 years (OVER; catch-up of mortality). A comparison of endovascular with openrepair of abdominalaorticaneurysm in propensity-score matched cohorts of Medicare beneﬁ ciaries found that endovascularrepair was associated with early survival advantage that gradually decreased over time, with catch-up of mortality after 3 years. The rate of rupture after aneurysmrepair was signiﬁ cantly higher in those who had EVAR than openrepair. The UK EVAR trial 1 previously reported follow-up for aneurysm-related and total mortality up to 10 years, at which point no diﬀ erence was recorded between EVAR and openabdominalaneurysmrepair. No previous trial has used follow-up of endovascularrepair or openrepair after this time. An observational study done during 1990–2013, published in 2016, from a single institution in Queensland, Australia, reported no diﬀ erences in 5-year, 10-year, and 15-year survival between openrepair (n=982; median follow-up 6·5 years) and EVAR (n=358; median follow- up 4·0 years), but had incomplete patient reporting. A previous report from the EVAR trials data deﬁ ned a “cluster” of complications (eg, type I endoleak, type III endoleak, type II endoleak with sac expansion, kinking, and migration), which was associated with secondary aortic sac rupture with 67% risk of death. The Eurostar database reported that the rate of secondary sac rupture after endovascularrepair is low for the
Due to the non-specific clinical presentation of chronic contained rupture, the rupture may be delayed diagnosis. However, Jones et al. has suggested clinical and radiological criteria for the differential diagnosis of chronic contained rupture . These criteria include: 1) known AAA; 2) previous symptoms of pain that may have resolved; 3) stable condition and normal hematocrit; 3) CT scan showing a retroperitoneal hematoma. CT is considered as a gold standard for the diagnosis of aneurysm rupture. The CT images showed irregular edges if it is acute rupture whereas the chronic rupture appears as well-defined and encapsulated . In our case also, the patient developed severe backache for two months and CT finding was suggestive of retroperitoneal mass. Biopsy of the mass ruled out the possibility of neoplastic lesion and laparotomy confirmed the diagnosis of the aneurysm. The patient was referred to our clinic for further management due to high surgical risk. We suspected chronic contained rupture of the aneurysm based upon the criteria provided by Jones et al. as well as the clinical conditions of the patients when patient presented to the clinic with same complaints. Long term survival has been reported in radiologically proven chronic contained ruptures which were left untreated due to co-morbidity . However, there are several case-reports which indicate a need of urgent treatment for chronic contained rupture as it may progress to free rupture at any time even though there is hemodynamic stability [16,17]. Transabdominal repair of the AAA has been performed over the last 50 years. However, openrepair of AAA is not without risk of mortality. By contrast, endovascularaneurysmrepair (EVAR) has reduced physiological insult. EVAR is dependent upon aneurysm morphology. When an aneurysm has diameter less than 30mm, length greater than 10 mm and angulation less than 60, the aneurysm is considered suitable for EVAR . In our case, the aneurysm was suitable for EVAR. Hsiao et al. has also reported the feasibility and safety of Zenith AAA bifurcated device for contained rupture in hemodynamically stable patient . We decided to treat the patient with bifurcation stenting.
The UKSAT 12 has enabled a comparison of the NHS costs and benefits of surgicalversus a more conservative regimen involving radiological assessment. 12 The analysis indicates that for aneurysms of 40-55mm diameter the conservative ‘watch and wait’ regimen is cheaper than early surgical interventions over a wide range of assumptions (£5,000 versus £4,000 at 1996/97 prices using a 6% discounting rate). The cost of ER was estimated at £6,800, though this figure is calculated using only a small sub-group of the whole trial population (12/1,090). In contrast to the Hölzenbein results, this UK study indicates a higher cost for endovascular compared with openrepair, although the costs of both procedures are considerably less than those estimated in Austria. Having said this, the UK estimate for the endovascular costs did use the unrepresentative ITU length of stay data from the Austrian study, which will have increased the estimated costs for this procedure. Jepson 57 has estimated the cost of elective AAA repair at £4,600 (1993 prices) in Scotland. Allowing for inflation, this is a similar figure to that reported by the UKSAT.
Abdominalaorticaneurysm (AAA) is a localized dilatation of the abdominal aorta exceeding the normal diameter by more than 50 percent, and is the most common form of aorticaneurysm. Abdominalaortic aneurysms are found in up to 8% of men over the age of 65 years. Rupture of an AAA and its associated catastrophic physiological insult carries an overall mortality in excess of 80%, and 2% of all deaths are AAA-related . The most common treatment for a large (>5 centimeters), unruptured aneurysm is opensurgicalrepair by a vascular surgeon. The aneurysm is cut and sewn in a graft to act as a bridge for the blood flow. The blood flow then goes through the plastic graft and no longer allows the direct pulsation pressure of the blood to further expand the weak aorta wall . Interventional repair is a less invasive method of placing a graft within the aneurysm to redirect the blood flow and stop direct pressure from being exerted on the weak aortic wall. This relatively new method eliminates the need for a large abdominal incision. It also eliminates the need to clamp the aorta during the procedure. Clamping the aorta creates a significant stress on the heart, and people with severe heart disease may not be able to tolerate this major surgery -. The most complicated endovascular post-operation compliance is aneurysm growing even in the absence of endoleak and this is considered to be a treatment failure with the risk of rupture. This condition is described as “endotension” . While the pathophysiology of other endovascular post-operation compliance is beginning to be elucidated, controversy still exists about the etiology and clinical consequences of endotension.
Decreased perioperative morbidity and mortality of endovascularabdominalaorticaneurysmrepair (EVAR) offers an attractive alternative to opensurgicalrepair. 1,2 However, the financial commitment involved with the high cost of the endograft device and compulsatory long-term surveillance may limit the widespread application of this procedure as a cost-effective alternative. 3,4 Initial enthusi- asm that the cost savings from shortened operative time, intensive care unit stay, and length of overall hospital stay would compensate for the high endograft device cost has been tempered by the failure of reimbursement to meet the initial cost of EVAR. 5-8 The noticeable increase in price of endograft devices since the approval of their use in 1999 by the US Food and Drug Administration further exacerbates this disparity. 8
screening study was found to have a higher prevalence in men (up to 7.6%) than women (1.3%) . Endovas- cular repair of abdominalaortic aneurysms has been demonstrated in clinical trials   to result in a lower 30-day mortality rate when compared to opensurgicalrepair. However the EVAR 2 Trial  demonstrated that in patients not fit for openrepair, the performance of EVAR provided no survival benefit. Furthermore the Dream trial bracket  participants reported a 5-year survival follow-up concluding no benefit for EVAR com- pared to openrepair. With the exception of the EVAR 2 Trial all patients entering these trials above were se- lected because they were fit to undergo either EVAR or openrepair. A report from the EUROSTAR Registry , found, “the mid-term outcome of large aneurysms after EVAR was associated with an increased rate of aneu- rysm related death, unrelated death and rupture”. Brewster et al.  in a similar registry report, in which 20% of the patient’s were unfit for openrepair, concluded “EVAR using contemporary devices is a safe, effective and durable method to prevent aorticaneurysm rupture and aneurysm related death.”
Patients treated for abdominalaorticaneurysm from April to December 2012 were divided into two groups. The first group underwent openabdominal surgery (OP), and the other group underwent endovascularaneurysm re- pair (SG). Cases were omitted if the patient received preoperative steroid treatment, the surgery combined mul- tiple procedures such as open heart surgery, or the patient had inflammatory diseases such as vasculitis. Pre- operative peripheral blood was taken to measure the baseline levels of endotoxin (Et), body temperature, white blood cell count (WBC), CRP, tumor necrosis factor α (TNF-α), and interleukin 6 (IL-6). Among them, WBC and CRP were measured in central laboratory of Juntendo University, and TNF- α , IL-6 were measured by out- sourcing laboratory (SRL Inc, Tokyo). These values were also measured postoperatively until postoperative day 5 to calculate the rate of change. Patient information such as age, gender, BMI, medication, complications, pre- vious surgical history including procedure, device used, operative time, and postoperative course were recorded and compared between the two groups.
gery  and case-control studies have shown a clear association between aortic valve stenosis and non-fatal myocardial infarction [20,21] after elective non-cardiac surgery. In their guideline, American College of Cardi- ologists and American Heart Association, firmly states that severe aortic valve disease poses the greatest risk for non-cardiac surgery  and that elective non-cardiac surgery should be postponed or canceled in symptomatic patients with aortic valve disease or in asymptomatic patients with severe valve disease if the valve has not been evaluated within the year. Patients with symptom- matic aortic valve disease require aortic valve replace- ment before any necessary elective non-cardiac surgery  to avoid a surgical mortality risk of 10%. Even though it seems that the cardiovascular response after EVAR, in comparison to openrepair of AAA, may be less pronounced [24-26], the present study mortality data support the view that patients with severe valve disease, particularly aortic valve stenosis, should be referred to a cardiologist for medical optimization and in case of aor- tic valve stenosis, considering referral to the cardio-tho- racic surgeon for aortic valve replacement.
Variability in reporting of outcomes, particularly renal outcomes, may have significantly affected the conclusions drawn. FEVAR is a complex endovascular procedure, asso- ciated with a significant learning curve. To reduce the effects of this, contemporary studies were used to remove study data obtained while the technique was being devel- oped. It should be noted, however, that although current experience of OSR outweighs that of FEVAR, the tendency towards endovascular techniques results in a shortfall in trainee experience of OSR. Results of complex OSR have likely plateaued and may begin to see a downward trend 47 .
In this study, which represents surgical decision making in a real-world, community hospital setting, it was shown that patients who were selected for EVAR had a trend to lower baseline SF-36 physical health composite scores than those undergoing OSR. This may reflect the clinical decision to prefer EVAR over OSR in patients with poorer health, who may be at a greater risk for complications from openrepair.
The most important ﬁnding of this study is that it high- lights the potential for the use of simulation training for teaching complex simulated open vascular procedures. We believe that simulation training cannot substitute for actual operating experience, but rather may prove an important tool to help trainees improve performance in operations and maximize the educational beneﬁt they reap from them. We selected open AAA repair as this is a procedure where there may be particular need for simu- lation training to supplement operative experience. With the advent of endovascularrepair of abdominalaortic aneu- rysms, the percentage of open repairs has declined dramat- ically. 28 In addition, new training paradigms, such as the 0þ5 vascular residency, as well as work hour restrictions, may limit the time available for open operative experience. Experience in open AAA repair, as well as other openaortic operations, is therefore diminishing. Between 2000 and 2009, Accreditation Council on Graduate Medical Educa- tion case logs have demonstrated a 55% decrease in the number of open elective AAA repairs performed by vascular surgery trainees. 29 Our group and others have identiﬁed the need for open vascular simulation as operative exposure to openaortic and other complex open vascular operations decreases. 10 In a recent survey of attending vascular surgeons and vascular fellows, open ruptured infrarenal aorticaneurysmrepair was identiﬁed as the second-most essential procedure for simulation, with high priority also given to elective, open infrarenal aorticaneurysmrepair. 30
The late aneurysm-related death rate was higher in TE- VAR group (10.0% vs. 4.2%, p=0.35), although did not reach statistical difference. There were 11 late aneurysm-re- lated deaths after TEVAR, which includes 3 deaths related to retrograde dissection, 4 related to surgical conversion due to endoleak, and 4 related to aneurysm rupture due to endole- ak. There were 2 late aneurysm-related death after open re- pair, which includes 1 death related to rupture of anastomo- sis site, and 1 related to rupture of abdominalaortic aneu- rysm. As mentioned earlier, retrograde dissection and endo- leak in the present study were significant complications, leading to catastrophic results. These significant complica- tions may contribute to our relatively poor result of an aneu- rysm-related death rate after TEVAR. However, most of the late aneurysm-related deaths (8/11) occurred in patients who present study, 33 patients (58.5%) in the openrepair group
Ultrasound-guided access into the common femoral arteries is achieved before induction of anesthesia to allow for sheath and wire placement into the aorta. Aortic balloon occlusion is initiated, if hemodynamic instability is present, as previously described. 19,20 Two Perclose ProGlide suture-mediated closure devices (Abbott Laboratories, Ab- bott Park, Ill) are fired (Perclose technique) to avoid the need for surgical femoral artery exposure. We routinely use ultrasound-guided access and the Perclose technique dur- ing elective EVAR repairs to facilitate rapid and consistent technical results during rAAA repair. If unstable, percuta- neous closure can be delayed until the repair has been completed.
Between April 2008 and May 2009, 43 patients without overt evidence of lower extremity arterial occlusive disease scheduled for elective infrarenal AAA repair were studied prospectively. All patients had an AAA larger than 5 cm in maximum diameter or an increase in aneurysm diameter more than 1 cm over the previous year. Exclusion criteria included: urgent or emergent AAA operation, re-do aortic surgery, anticipated aortic clamping proximal to a renal artery, prior lower extremity amputation, or evidence of concomitant peripheral arterial occlusive disease as manifest by a history of claudication, previous lower extrem- ity bypass surgery, or absence of easily palpable pedal pulses. All patients were evaluated with contrast enhanced computed tomography (CT) preoperatively to define aneurysm morphol- ogy. The operative approach for AAA repair was at the discretion of the operating surgeon, member of the vascular surgery division of Henry Ford Medical Group (HFMG).
and after reperfusion), and perioperative administration of the excitatory neurotransmitter inhibitor naloxone. Spinal drains are routinely left in place for 48 hours, unless clinical parameters mandate longer drainage intervals. The spinal drains are capped when lower extremity motor func- tion is consistently demonstrated. In addition to the inter- ventions above, systemic steroids are administered shortly after anesthesia induction, and mannitol is given just before endovascular device deployment. The ability to stage repair has also been shown to effectively reduce paraplegia rates, presumably by allowing collateral pathways to mature and augment the spinal perfusion. 27
techniques have gained popularity as a possible alterna- tive to openrepair or standard EVAR techniques that would not compromise blood perfusion to the aortic side branches, since the sealing and/or fixation zone is translocated proximal or distal away from the target vessels [4,5]. However, the endovascular stent grafts that are used in the fenestrated and branched EVAR are custom-made and require measuring, fitting and a period of time for graft preparation and supply. Therefore, these two costly techniques are only suitable for elective repair of AAA and not in emergent cases [1,2,4,5]. In 2003, Greenberg et al, have introduced the novel chimney graft (CG) procedure (a.k.a. the “snorkel technique”) in order to overcome some of the limitations of the fenestrated and branched EVAR . The CG technique involves placing of parallel stent grafts adjacent to the main body of the aortic endograft to maintain blood supply to renal and other visceral branches post- aneurysm exclusion. Contrary to EVAR with the fenestrated or branched technique, the CG technique involves standard off-the-shelf stent grafts and can be used in emergent cases [1,2]. Possible indications for the use of CGs, other than treating suprarenal and juxtarenal abdominalaortic aneurysms, include thoracic and thoracoabdominal aneu- rysms with supraortic branches orifice involvement and suitable cases of common iliac artery aneurysms with or without internal iliac artery involvement [7,8]. A potential major drawback of the EVAR procedures is the presence of endoleaks (i.e. persistent flow of blood into the aneurysm sac after device placement). Endoleaks were reported to complicate up to 25% of EVAR operations with CG placement. However, endoleak repair not ne- cessary in most cases .