Endovascular Aortic Aneurysm Repair

To the Editor: Endovascular aortic aneurysm repair (EVAR) has emerged as a popular alternative to open surgical repair for abdominal aortic aneurysms (AAAs), with a major increase in the number of procedures performed in the United States.¹ A lower operative mortality and morbidity from this less invasive procedure when compared with open surgical repair partly fueled the enthusiasm surrounding its use.^{2 - 3}

In his Clinical Crossroads article reviewing management of AAA, Dr Schermerhorn³ stated that EVAR may be used to treat “older, sicker patients . . . who would not have been considered for repair when open surgery was the only choice.” However, results of the EVAR 2 trial, which sought to specifically address whether EVAR would benefit patients considered unfit for open surgical repair, casts considerable doubt on this assertion.⁴

EVAR 2 was a randomized controlled trial of 338 patients aged 60 years or older with more cardiopulmonary comorbidities than those in EVAR 1.² Patients were assigned to receive either EVAR or no intervention and were followed up for 4 years. There were no significant differences in the primary end point of all-cause mortality between the groups (hazard ratio, 1.21; 95% confidence interval, 0.87-1.69; P = .25) or in aneurysm-related mortality. However, there was substantial in-hospital and preprocedural mortality and higher costs associated with continued surveillance and reinterventions in the group randomized to EVAR. Therefore, whether EVAR can provide a survival advantage to patients deemed high-risk and unfit for open surgical repair is unclear, and EVAR is not endorsed as an option in this subset of patients by the Society of Vascular Surgery.⁵