Endovascular vs Open AAA Repair: Does Size Matter?

Abstract

Since the natural tendency of the aorta is to increase in diameter and tortuosity with age and since abdominal aortic aneurysms (AAAs) increase in diameter and length over time, encroaching on the renal and hypogastric orifices, early repair of AAAs (when =4.0 cm) may allow greater applicability of the endovascular option because of more favorable aortoiliac morphology. Patients who present at an older age with larger AAAs should be more likely to be anatomically excluded from endovascular AAA repair. Over a 42-month period, 317 consecutive patients referred with aortoiliac aneurysms (infrarenal AAA =4.0 cm) were evaluated by one of the authors (SGL) for endovascular vs open repair based on computed tomography (CT) and angiographic imaging. The 10 anatomic exclusion criteria were those applicable to the Zenith ^® endograft (Cook, Inc), which currently is the most anatomically inclusive of the aortic endografts in commercial use in the United States. Based on their aortoiliac morphology, 212 patients were excluded from endovascular repair and 105 were included as acceptable anatomic candidates. Age, AAA size, and the reason(s) for exclusion were recorded for each patient. By use of Student's t test and logistic and linear regression analyses, the groups were compared by age, AAA size, and age + size. There was no significant difference in patient age or AAA size distribution between the group of patients excluded from endovascular repair based on aortoiliac morphology compared to those who met the inclusion criteria. Patients with small AAAs (4.0–5.4 cm) had similar age distribution as those with large (=5.5 cm) AAAs. The majority of patients (87%) were excluded based on proximal aortic neck morphology. The presence of aortoiliac morphology that precludes endovascular repair is independent of patient age or AAA size at presentation. A patient presenting with a small (4.0–5.4 cm) AAA is not more likely to be a candidate for endovascular repair than a patient with a large AAA.

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References

Stanley BM , Semmens JB , Mai Q , et al: Evaluation of patient selection guidelines for endoluminal AAA repair with the Zenith stent-graft: The Australasian experience. J Endovasc Ther 8:457-464, 2001.

Arko FR , Filis KA , Seidel SA , et al: How many patients with infrarenal aneurysms are candidates for endovascular repair? The Northern California experience. J Endovasc Ther 11:33-40, 2004.

Lanne T , Sonesson B , Bergquist D , et al: Diameter and compliance in the male human abdominal aorta: Influence of age and aortic aneurysm. Eur J Vasc Surg 6:178-184, 1992.

Sonesson B , Lanne T , Hansen F , et al: Infrarenal aortic diameter in the healthy person. Eur J Vasc Surg 8:89-98, 1994

D'Audiffret A , Santilli S , Tretinyak A , et al: Fate of the ectatic infrarenal aorta: Expansion rates and outcomes. Ann Vasc Surg 16:534-536, 2002.

Dobrin PB : Physiology and pathophysiology of blood vessels. In: The Basic Science of Vascular Disease, ed. by Sidawy AN , Sumpio BE , DePalma RG . Armonk, NY: Futura Publishing, 1997, pp 69-105.

Ouriel K , Tanquilut E , Greenberg RK , et al: Aortoiliac morphologic correlations in aneurysms undergoing endovascular repair. J Vasc Surg 38:323-328, 2003.

Peppelenbosch N , Buth J , Harris PL , et al: Diameter of abdominal aortic aneurysm and outcome of endovascular aneurysm repair: Does size matter? A report from Eurostar. J Vasc Surg 39:288-297, 2004.

Resch T , Ivancev K , Lindh M , et al: Abdominal aortic aneurysm morphology in candidates for endovascular repair evaluated with spiral computed tomography and digital subtraction angiography. J Endovasc Surg 6:227-232, 1999.

10.

Greenberg RK , Chuter TAM , Sternbergh WC , et al: Zenith AAA endovascular graft: Intermediate-term results of the US multicentral trial. J Vasc Surg 39:1209-1218, 2004.

11.

Greenberg RK , Clair D , Srivastava S , et al: Should patients with challenging anatomy be offered endovascular aneurysm repair? J Vasc Surg 38:990-996, 2003.

12.

Sternbergh WC III , Carter G , York JW , et al: Aortic neck angulation predicts adverse outcome with endovascular abdominal aortic aneurysm repair. J Vasc Surg 35:482-486, 2002.

13.

Carpenter JP , Baum RA , Barker CF , et al: Impact of exclusion criteria on patient selection for endovascular abdominal aortic aneurysm repair. J Vasc Surg 34:1050-1054, 2001.

14.

Gitlitz DB , Ramaswami G , Kaplan D : Endovascular stent grafting in the presence of aortic neck filling defects: Early clinical experience. J Vasc Surg 33: 340-344, 2001.

15.

Armon MP , Yusuf SW , Whitaker SC , et al: Influence of abdominal aortic aneurysm size on the feasibility of endovascular repair. J Endovasc Surg 4:279-283, 1997.

16.

Schumacher H , Eckstein HH , Kallinowski F , et al: Morphometry and classification in abdominal aortic aneurysms: Patient selection for endovascular and open surgery. J Endovasc Surg 4:39-44, 1997.

17.

Zarins CK , Wolf YG , Lee WA , et al: Will endovascular repair replace open surgery for abdominal aortic aneurysm repair? Ann Surg 232:501-507, 2000.

18.

Woodbrun KR , Chant H , Davis JN , et al: Suitability for endovascular aneurysm repair in an unselected population. Br J Surg 88:77-81, 2001.

19.

The United Kingdom Small Aneurysm Trial Participants: Mortality results for randomized controlled trial of early elective surgery or ultrasonographic surveillance for small abdominal aortic aneurysms. Lancet 352:1649-1655, 1998.

20.

Lederle FA , Wilson SE , Johnson GR , et al: Immediate repair compared with surveillance of small abdominal aortic aneurysms. N Engl J Med 346:1437-1444, 2002.