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Once again our authorities choose to agree rather than disagree. Although there may be some minor differences in opinion, it appears that both suggest that careful observation is the preferred management for small abdominal aortic aneurysms. However, there may still be some controversy since I believe the data they use to support observation is confounded by including patients whose aneurysms were less than 5 cm. I think almost everyone would agree that it is safe to monitor the <5 cm AAA. But what about the 5.2 cm in a small woman or a patient with chronic obstructive pulmonary disease or a strong family history of rupture or, for that matter, in any patient? If you have an opinion one way or another I invite you to send your comments to [email protected] for inclusion in a future edition of Vascular Specialist. In the meantime if you go to www.Vascularspecialistonline.com you can respond to our "Online Question of the Month" about the treatment of these small AAA.
--Dr. Russell Samson is the medical editor of Vascular Specialist.
Procedural risks remain an issue.
By Kenneth Ouriel, M.D.
Abdominal aortic aneurysms (AAA) are treated to prevent death from aneurysm rupture. Depending on the patient’s baseline medical status, however, the risks of the procedure itself may outweigh the risks of leaving the aneurysm untreated.1 Endovascular aneurysm repair (EVAR), originally developed as a less invasive alternative to traditional open surgery,2 has incompletely addressed this issue. While prospective randomized clinical trials demonstrated reduction in early morbidity and mortality with EVAR, early benefits have not translated into long-term survival benefit over open surgical repair.3,4
Several studies have demonstrated improved results with EVAR when performed in patients with smaller aneurysms.5,6 This observation may relate to the frequency of more challenging anatomy in larger aneurysms, with a higher frequency of shorter, larger diameter, angulated, and conical proximal aortic necks. While the potential benefit of repair in patients with larger aneurysms is greatest with respect to the prevention of rupture, some of this benefit may be offset by poorer long-term outcome. These results are only in part a function of complications related to the device, such as proximal endoleaks and migration. In addition, patients with larger aneurysms are slightly older and sicker than those with smaller aneurysms, accounting for an increased frequency of non-aneurysm related events.
Noting the less challenging aortic anatomy and younger, healthier characteristics of the subpopulation with smaller AAA, two randomized studies were organized to compare the results of early endovascular repair versus ultrasound or computed tomographic (CT) surveillance.7 The PIVOTAL trial enrolled 728 subjects with AAA between 4 and 5 cm in diameter, randomizing to either early EVAR with the AneuRx or Talent endografts or to ultrasound/CT imaging studies every 6 months. The perioperative mortality rate was 0.6% in the early EVAR group. Over a mean follow-up period of 20 months, there were no differences in all-cause mortality between the two groups, each with 15 deaths (4.1%). The primary endpoint of rupture or aneurysm-related death was similar in the two groups, with a hazard ratio of 0.99 in the early EVAR group. However, at 36 months almost 50% of the surveillance group underwent aneurysm repair for sac enlargement, the development of aneurysm-related symptoms, or patient choice. Interestingly, a follow-up economic substudy documented similar health care costs in the two treatment groups at 48 months of follow-up, even though 36.3% of the surveyed patients did not undergo repair.
A second study, the CEASAR trial, randomized 360 patients with AAA 4.1-5.4 cm in diameter to early EVAR with the Cook Zenith device or to serial ultrasound surveillance. After 4.5 years of follow-up, no significant difference was detected in the primary endpoint of all-cause mortality. The Kaplan-Meier estimates of all-cause mortality was 14.5% in the early repair group versus 10.1% in the surveillance group. Aneurysm-related mortality, aneurysm rupture, and major morbidity rates were similar. Like the PIVOTAL trial, the majority of subjects underwent delayed repair, with a frequency of 60% at 3-years and 85% at 4.5 years.
The findings of these two randomized studies suggest that there is no survival advantage to early EVAR in patients with smaller AAA. With the increasing use of statins, ACE inhibitors, and better overall medical management in patients with AAA, the rate of aneurysm enlargement and risk of rupture are quite low in patients with small AAA.8 While survival benefits have not been demonstrated, however, there appear to be few quantifiable disadvantages to early repair. Moreover, the long-term financial impact to the healthcare system appears to be similar when patients are treated early compared to surveillance with serial imaging studies,9 and patient quality of life may be improved with early EVAR.10 These observations suggest that the repair of smaller AAA should be individualized, based upon the particular clinical presentation and the wishes of a patient. The summary of available data suggests that either approach protects a patient from rupture and surveillance culminates in the eventual repair of the aneurysm in the majority of patients.
Dr. Ouriel is a vascular surgeon and president and CEO of Syntactx.
References
1. J Vasc Surg, 2012. 55(5): p. 1263-7.
2. J Vasc Interv Radiol, 2012. 23(7): p. 866-72; quiz 872.
3. J Endovasc Ther, 2012. 19(2): p. 182-92.
4. J Vasc Surg, 2012. 55(1): p. 33-40.
5. Ann Vasc Surg, 2012. 26(6): p. 860 e1-7.
6. J Vasc Interv Radiol, 2013. 24(1): p. 49-55
7. J Vasc Surg, 2012. 56(3): p. 630-6.
8. J Cardiovasc Surg (Torino), 2013. 1. Br J Surg 2007;94:702-8.
2. Semin Interv Cardiol 2000;5:3-6.
3. NEnglJMed 2010;362:1863-71.
4. JAMA 2009;302:1535-42.
5.. J Vasc Surg 2003;37:1206-12.
6. J Vasc Surg 2006;44:920-29; discussion 9-31.
7. J Vasc Surg 2010;51:1081-7.
8. EurJVascEndovascSurg 2011;41:2-10.
9. J Vasc Surg 2013;58:302-10.
10. Eur J Vasc Endovasc Surg 2011;41:324-31.
Small aneurysms should be left alone.
By Karl A. Illig, M.D.
The currently accepted recommendation to delay repair of abdominal aortic aneurysms until they reach 5-5.5 cm is based on the historical mortality and morbidity of open repair.1 Endovascular aneurysm repair (EVAR) has clearly been shown to reduce the risk of operation, perhaps by as much as two-thirds. Should we now change the threshold for aneurysm repair, especially if the patient is a candidate for EVAR?
There are many arguments to repair small aneurysms. However, the answer really depends upon empirical data. At least three major papers address this question. In the U.K. Small Aneurysm Trial, 1,090 patients with abdominal aortic aneurysms measuring 4.0-5.5 cm in diameter were randomized to undergo early elective open surgery versus ultrasonic surveillance.2 There was an early survival disadvantage for those undergoing open surgery, as expected, but the curves evened out at 3 years or so, and no survival advantage occurred in either group, obviously favoring observation alone. Similarly, the ADAM group, pursuing the same protocol in 1,136 U.S. veterans, found the same thing, despite a low operative mortality of 2.7%. No advantage to early open repair could be seen.3
What of the situation after endovascular repair? The PIVOTAL trial, the lead author of which wrote the accompanying commentary, randomly assigned 728 patients with aneurysms measuring 4.0-5.0 cm to early endovascular repair with the Medtronic device versus ultrasonic surveillance.4 Aneurysm rupture or aneurysm-related death occurred in only two patients in each group (0.6%). The authors appropriately concluded that surveillance alone was equally as efficacious as early endovascular repair for patients with small aneurysms.
Finally, what of the arguments that, by waiting until the aneurysm is larger, you lose the window of opportunity for endovascular repair? We recently explored this in a cohort of 221 patients undergoing preoperative CT scanning for aneurysms of all sizes.5 With receiver operator curve analysis, a cutoff of 5.7 cm best differentiated those who were endovascular candidates from those who were not. Put another way, the rate of endovascular suitability hovered right around 80% until the aneurysm reached 6 cm, at which point it dropped off. In other words, waiting until the aneurysm reaches 5.5 cm doesn’t reduce the chance that a patient will be a candidate for EVAR.
There are many arguments for early intervention in small aneurysms. The concept that EVAR is safer than the procedure originally used to make the recommendation to wait until 5.5 cm is a valid point. However, empiric data still do not show any benefit for either open or endovascular repair as opposed to surveillance at sizes smaller than this. The operative mortality difference is only a couple of percentage points or so, and long-term survival appears to be identical after the initial risk has passed. This 2% or 3% early survival benefit does not seem to impart any long-term advantage, and long-term survival does not seem to be impaired by being a bit conservative. Until data come along that definitively show benefit for early repair, current guidelines remain valid.
Dr. Illig is the director of vascular surgery at USF Health, Tampa.
References:
1. J Vasc Surg 2009;50(8S):1S-49S.
2. Lancet 1998; 352:1649-55.
3. NEJM 2002; 346 (19): 1437-44.
4. J Vasc Surg 2010; 51:1081-7.
5. J Vasc Surg 2010;52:873-7.
Once again our authorities choose to agree rather than disagree. Although there may be some minor differences in opinion, it appears that both suggest that careful observation is the preferred management for small abdominal aortic aneurysms. However, there may still be some controversy since I believe the data they use to support observation is confounded by including patients whose aneurysms were less than 5 cm. I think almost everyone would agree that it is safe to monitor the <5 cm AAA. But what about the 5.2 cm in a small woman or a patient with chronic obstructive pulmonary disease or a strong family history of rupture or, for that matter, in any patient? If you have an opinion one way or another I invite you to send your comments to [email protected] for inclusion in a future edition of Vascular Specialist. In the meantime if you go to www.Vascularspecialistonline.com you can respond to our "Online Question of the Month" about the treatment of these small AAA.
--Dr. Russell Samson is the medical editor of Vascular Specialist.
Procedural risks remain an issue.
By Kenneth Ouriel, M.D.
Abdominal aortic aneurysms (AAA) are treated to prevent death from aneurysm rupture. Depending on the patient’s baseline medical status, however, the risks of the procedure itself may outweigh the risks of leaving the aneurysm untreated.1 Endovascular aneurysm repair (EVAR), originally developed as a less invasive alternative to traditional open surgery,2 has incompletely addressed this issue. While prospective randomized clinical trials demonstrated reduction in early morbidity and mortality with EVAR, early benefits have not translated into long-term survival benefit over open surgical repair.3,4
Several studies have demonstrated improved results with EVAR when performed in patients with smaller aneurysms.5,6 This observation may relate to the frequency of more challenging anatomy in larger aneurysms, with a higher frequency of shorter, larger diameter, angulated, and conical proximal aortic necks. While the potential benefit of repair in patients with larger aneurysms is greatest with respect to the prevention of rupture, some of this benefit may be offset by poorer long-term outcome. These results are only in part a function of complications related to the device, such as proximal endoleaks and migration. In addition, patients with larger aneurysms are slightly older and sicker than those with smaller aneurysms, accounting for an increased frequency of non-aneurysm related events.
Noting the less challenging aortic anatomy and younger, healthier characteristics of the subpopulation with smaller AAA, two randomized studies were organized to compare the results of early endovascular repair versus ultrasound or computed tomographic (CT) surveillance.7 The PIVOTAL trial enrolled 728 subjects with AAA between 4 and 5 cm in diameter, randomizing to either early EVAR with the AneuRx or Talent endografts or to ultrasound/CT imaging studies every 6 months. The perioperative mortality rate was 0.6% in the early EVAR group. Over a mean follow-up period of 20 months, there were no differences in all-cause mortality between the two groups, each with 15 deaths (4.1%). The primary endpoint of rupture or aneurysm-related death was similar in the two groups, with a hazard ratio of 0.99 in the early EVAR group. However, at 36 months almost 50% of the surveillance group underwent aneurysm repair for sac enlargement, the development of aneurysm-related symptoms, or patient choice. Interestingly, a follow-up economic substudy documented similar health care costs in the two treatment groups at 48 months of follow-up, even though 36.3% of the surveyed patients did not undergo repair.
A second study, the CEASAR trial, randomized 360 patients with AAA 4.1-5.4 cm in diameter to early EVAR with the Cook Zenith device or to serial ultrasound surveillance. After 4.5 years of follow-up, no significant difference was detected in the primary endpoint of all-cause mortality. The Kaplan-Meier estimates of all-cause mortality was 14.5% in the early repair group versus 10.1% in the surveillance group. Aneurysm-related mortality, aneurysm rupture, and major morbidity rates were similar. Like the PIVOTAL trial, the majority of subjects underwent delayed repair, with a frequency of 60% at 3-years and 85% at 4.5 years.
The findings of these two randomized studies suggest that there is no survival advantage to early EVAR in patients with smaller AAA. With the increasing use of statins, ACE inhibitors, and better overall medical management in patients with AAA, the rate of aneurysm enlargement and risk of rupture are quite low in patients with small AAA.8 While survival benefits have not been demonstrated, however, there appear to be few quantifiable disadvantages to early repair. Moreover, the long-term financial impact to the healthcare system appears to be similar when patients are treated early compared to surveillance with serial imaging studies,9 and patient quality of life may be improved with early EVAR.10 These observations suggest that the repair of smaller AAA should be individualized, based upon the particular clinical presentation and the wishes of a patient. The summary of available data suggests that either approach protects a patient from rupture and surveillance culminates in the eventual repair of the aneurysm in the majority of patients.
Dr. Ouriel is a vascular surgeon and president and CEO of Syntactx.
References
1. J Vasc Surg, 2012. 55(5): p. 1263-7.
2. J Vasc Interv Radiol, 2012. 23(7): p. 866-72; quiz 872.
3. J Endovasc Ther, 2012. 19(2): p. 182-92.
4. J Vasc Surg, 2012. 55(1): p. 33-40.
5. Ann Vasc Surg, 2012. 26(6): p. 860 e1-7.
6. J Vasc Interv Radiol, 2013. 24(1): p. 49-55
7. J Vasc Surg, 2012. 56(3): p. 630-6.
8. J Cardiovasc Surg (Torino), 2013. 1. Br J Surg 2007;94:702-8.
2. Semin Interv Cardiol 2000;5:3-6.
3. NEnglJMed 2010;362:1863-71.
4. JAMA 2009;302:1535-42.
5.. J Vasc Surg 2003;37:1206-12.
6. J Vasc Surg 2006;44:920-29; discussion 9-31.
7. J Vasc Surg 2010;51:1081-7.
8. EurJVascEndovascSurg 2011;41:2-10.
9. J Vasc Surg 2013;58:302-10.
10. Eur J Vasc Endovasc Surg 2011;41:324-31.
Small aneurysms should be left alone.
By Karl A. Illig, M.D.
The currently accepted recommendation to delay repair of abdominal aortic aneurysms until they reach 5-5.5 cm is based on the historical mortality and morbidity of open repair.1 Endovascular aneurysm repair (EVAR) has clearly been shown to reduce the risk of operation, perhaps by as much as two-thirds. Should we now change the threshold for aneurysm repair, especially if the patient is a candidate for EVAR?
There are many arguments to repair small aneurysms. However, the answer really depends upon empirical data. At least three major papers address this question. In the U.K. Small Aneurysm Trial, 1,090 patients with abdominal aortic aneurysms measuring 4.0-5.5 cm in diameter were randomized to undergo early elective open surgery versus ultrasonic surveillance.2 There was an early survival disadvantage for those undergoing open surgery, as expected, but the curves evened out at 3 years or so, and no survival advantage occurred in either group, obviously favoring observation alone. Similarly, the ADAM group, pursuing the same protocol in 1,136 U.S. veterans, found the same thing, despite a low operative mortality of 2.7%. No advantage to early open repair could be seen.3
What of the situation after endovascular repair? The PIVOTAL trial, the lead author of which wrote the accompanying commentary, randomly assigned 728 patients with aneurysms measuring 4.0-5.0 cm to early endovascular repair with the Medtronic device versus ultrasonic surveillance.4 Aneurysm rupture or aneurysm-related death occurred in only two patients in each group (0.6%). The authors appropriately concluded that surveillance alone was equally as efficacious as early endovascular repair for patients with small aneurysms.
Finally, what of the arguments that, by waiting until the aneurysm is larger, you lose the window of opportunity for endovascular repair? We recently explored this in a cohort of 221 patients undergoing preoperative CT scanning for aneurysms of all sizes.5 With receiver operator curve analysis, a cutoff of 5.7 cm best differentiated those who were endovascular candidates from those who were not. Put another way, the rate of endovascular suitability hovered right around 80% until the aneurysm reached 6 cm, at which point it dropped off. In other words, waiting until the aneurysm reaches 5.5 cm doesn’t reduce the chance that a patient will be a candidate for EVAR.
There are many arguments for early intervention in small aneurysms. The concept that EVAR is safer than the procedure originally used to make the recommendation to wait until 5.5 cm is a valid point. However, empiric data still do not show any benefit for either open or endovascular repair as opposed to surveillance at sizes smaller than this. The operative mortality difference is only a couple of percentage points or so, and long-term survival appears to be identical after the initial risk has passed. This 2% or 3% early survival benefit does not seem to impart any long-term advantage, and long-term survival does not seem to be impaired by being a bit conservative. Until data come along that definitively show benefit for early repair, current guidelines remain valid.
Dr. Illig is the director of vascular surgery at USF Health, Tampa.
References:
1. J Vasc Surg 2009;50(8S):1S-49S.
2. Lancet 1998; 352:1649-55.
3. NEJM 2002; 346 (19): 1437-44.
4. J Vasc Surg 2010; 51:1081-7.
5. J Vasc Surg 2010;52:873-7.
Once again our authorities choose to agree rather than disagree. Although there may be some minor differences in opinion, it appears that both suggest that careful observation is the preferred management for small abdominal aortic aneurysms. However, there may still be some controversy since I believe the data they use to support observation is confounded by including patients whose aneurysms were less than 5 cm. I think almost everyone would agree that it is safe to monitor the <5 cm AAA. But what about the 5.2 cm in a small woman or a patient with chronic obstructive pulmonary disease or a strong family history of rupture or, for that matter, in any patient? If you have an opinion one way or another I invite you to send your comments to [email protected] for inclusion in a future edition of Vascular Specialist. In the meantime if you go to www.Vascularspecialistonline.com you can respond to our "Online Question of the Month" about the treatment of these small AAA.
--Dr. Russell Samson is the medical editor of Vascular Specialist.
Procedural risks remain an issue.
By Kenneth Ouriel, M.D.
Abdominal aortic aneurysms (AAA) are treated to prevent death from aneurysm rupture. Depending on the patient’s baseline medical status, however, the risks of the procedure itself may outweigh the risks of leaving the aneurysm untreated.1 Endovascular aneurysm repair (EVAR), originally developed as a less invasive alternative to traditional open surgery,2 has incompletely addressed this issue. While prospective randomized clinical trials demonstrated reduction in early morbidity and mortality with EVAR, early benefits have not translated into long-term survival benefit over open surgical repair.3,4
Several studies have demonstrated improved results with EVAR when performed in patients with smaller aneurysms.5,6 This observation may relate to the frequency of more challenging anatomy in larger aneurysms, with a higher frequency of shorter, larger diameter, angulated, and conical proximal aortic necks. While the potential benefit of repair in patients with larger aneurysms is greatest with respect to the prevention of rupture, some of this benefit may be offset by poorer long-term outcome. These results are only in part a function of complications related to the device, such as proximal endoleaks and migration. In addition, patients with larger aneurysms are slightly older and sicker than those with smaller aneurysms, accounting for an increased frequency of non-aneurysm related events.
Noting the less challenging aortic anatomy and younger, healthier characteristics of the subpopulation with smaller AAA, two randomized studies were organized to compare the results of early endovascular repair versus ultrasound or computed tomographic (CT) surveillance.7 The PIVOTAL trial enrolled 728 subjects with AAA between 4 and 5 cm in diameter, randomizing to either early EVAR with the AneuRx or Talent endografts or to ultrasound/CT imaging studies every 6 months. The perioperative mortality rate was 0.6% in the early EVAR group. Over a mean follow-up period of 20 months, there were no differences in all-cause mortality between the two groups, each with 15 deaths (4.1%). The primary endpoint of rupture or aneurysm-related death was similar in the two groups, with a hazard ratio of 0.99 in the early EVAR group. However, at 36 months almost 50% of the surveillance group underwent aneurysm repair for sac enlargement, the development of aneurysm-related symptoms, or patient choice. Interestingly, a follow-up economic substudy documented similar health care costs in the two treatment groups at 48 months of follow-up, even though 36.3% of the surveyed patients did not undergo repair.
A second study, the CEASAR trial, randomized 360 patients with AAA 4.1-5.4 cm in diameter to early EVAR with the Cook Zenith device or to serial ultrasound surveillance. After 4.5 years of follow-up, no significant difference was detected in the primary endpoint of all-cause mortality. The Kaplan-Meier estimates of all-cause mortality was 14.5% in the early repair group versus 10.1% in the surveillance group. Aneurysm-related mortality, aneurysm rupture, and major morbidity rates were similar. Like the PIVOTAL trial, the majority of subjects underwent delayed repair, with a frequency of 60% at 3-years and 85% at 4.5 years.
The findings of these two randomized studies suggest that there is no survival advantage to early EVAR in patients with smaller AAA. With the increasing use of statins, ACE inhibitors, and better overall medical management in patients with AAA, the rate of aneurysm enlargement and risk of rupture are quite low in patients with small AAA.8 While survival benefits have not been demonstrated, however, there appear to be few quantifiable disadvantages to early repair. Moreover, the long-term financial impact to the healthcare system appears to be similar when patients are treated early compared to surveillance with serial imaging studies,9 and patient quality of life may be improved with early EVAR.10 These observations suggest that the repair of smaller AAA should be individualized, based upon the particular clinical presentation and the wishes of a patient. The summary of available data suggests that either approach protects a patient from rupture and surveillance culminates in the eventual repair of the aneurysm in the majority of patients.
Dr. Ouriel is a vascular surgeon and president and CEO of Syntactx.
References
1. J Vasc Surg, 2012. 55(5): p. 1263-7.
2. J Vasc Interv Radiol, 2012. 23(7): p. 866-72; quiz 872.
3. J Endovasc Ther, 2012. 19(2): p. 182-92.
4. J Vasc Surg, 2012. 55(1): p. 33-40.
5. Ann Vasc Surg, 2012. 26(6): p. 860 e1-7.
6. J Vasc Interv Radiol, 2013. 24(1): p. 49-55
7. J Vasc Surg, 2012. 56(3): p. 630-6.
8. J Cardiovasc Surg (Torino), 2013. 1. Br J Surg 2007;94:702-8.
2. Semin Interv Cardiol 2000;5:3-6.
3. NEnglJMed 2010;362:1863-71.
4. JAMA 2009;302:1535-42.
5.. J Vasc Surg 2003;37:1206-12.
6. J Vasc Surg 2006;44:920-29; discussion 9-31.
7. J Vasc Surg 2010;51:1081-7.
8. EurJVascEndovascSurg 2011;41:2-10.
9. J Vasc Surg 2013;58:302-10.
10. Eur J Vasc Endovasc Surg 2011;41:324-31.
Small aneurysms should be left alone.
By Karl A. Illig, M.D.
The currently accepted recommendation to delay repair of abdominal aortic aneurysms until they reach 5-5.5 cm is based on the historical mortality and morbidity of open repair.1 Endovascular aneurysm repair (EVAR) has clearly been shown to reduce the risk of operation, perhaps by as much as two-thirds. Should we now change the threshold for aneurysm repair, especially if the patient is a candidate for EVAR?
There are many arguments to repair small aneurysms. However, the answer really depends upon empirical data. At least three major papers address this question. In the U.K. Small Aneurysm Trial, 1,090 patients with abdominal aortic aneurysms measuring 4.0-5.5 cm in diameter were randomized to undergo early elective open surgery versus ultrasonic surveillance.2 There was an early survival disadvantage for those undergoing open surgery, as expected, but the curves evened out at 3 years or so, and no survival advantage occurred in either group, obviously favoring observation alone. Similarly, the ADAM group, pursuing the same protocol in 1,136 U.S. veterans, found the same thing, despite a low operative mortality of 2.7%. No advantage to early open repair could be seen.3
What of the situation after endovascular repair? The PIVOTAL trial, the lead author of which wrote the accompanying commentary, randomly assigned 728 patients with aneurysms measuring 4.0-5.0 cm to early endovascular repair with the Medtronic device versus ultrasonic surveillance.4 Aneurysm rupture or aneurysm-related death occurred in only two patients in each group (0.6%). The authors appropriately concluded that surveillance alone was equally as efficacious as early endovascular repair for patients with small aneurysms.
Finally, what of the arguments that, by waiting until the aneurysm is larger, you lose the window of opportunity for endovascular repair? We recently explored this in a cohort of 221 patients undergoing preoperative CT scanning for aneurysms of all sizes.5 With receiver operator curve analysis, a cutoff of 5.7 cm best differentiated those who were endovascular candidates from those who were not. Put another way, the rate of endovascular suitability hovered right around 80% until the aneurysm reached 6 cm, at which point it dropped off. In other words, waiting until the aneurysm reaches 5.5 cm doesn’t reduce the chance that a patient will be a candidate for EVAR.
There are many arguments for early intervention in small aneurysms. The concept that EVAR is safer than the procedure originally used to make the recommendation to wait until 5.5 cm is a valid point. However, empiric data still do not show any benefit for either open or endovascular repair as opposed to surveillance at sizes smaller than this. The operative mortality difference is only a couple of percentage points or so, and long-term survival appears to be identical after the initial risk has passed. This 2% or 3% early survival benefit does not seem to impart any long-term advantage, and long-term survival does not seem to be impaired by being a bit conservative. Until data come along that definitively show benefit for early repair, current guidelines remain valid.
Dr. Illig is the director of vascular surgery at USF Health, Tampa.
References:
1. J Vasc Surg 2009;50(8S):1S-49S.
2. Lancet 1998; 352:1649-55.
3. NEJM 2002; 346 (19): 1437-44.
4. J Vasc Surg 2010; 51:1081-7.
5. J Vasc Surg 2010;52:873-7.
