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Aortic Intervention

Standard EVAR: The importance of durability

Fabio Verzini, MD, PhD, is Professor of Vascular Surgery at University of Peruqia. Hospital Santa Maria della Misericordia Italy. Dr. Verzini shares his thoughts on durability of standard EVAR after publishing 14-year data.

What are the goals of standard abdominal EVAR today?

To me, EVAR today is the gold standard therapy for patients with AAA. This is because it is much less invasive than open repair and especially in patients that are getting older and older with this disease. We need to have a very minimally invasive therapy that means less recovery time. What they want is to have a good quality of life for the remaining lifetime that they have without too much fear of late risk of death. Shortening the recovery time is very important or them to be able to go back home, enjoy their family life and do all the stuff that they are used to. I find EVAR really a wonderful solution especially for high-risk patients, where co-morbidities may eventually impede any open surgery.

EVAR is being used more and more in younger patients, and durability becomes more of an issue as they live longer. What have you learned in fifteen years of experience with EVAR?

On the other hand of the spectrum actually, there are these young patients that are still active and working, in which endografting is a great solution too. I strongly pay attention to their anatomic suitability before deciding for EVAR versus open repair. because the key issue is to address the right patient with the right tool. Definitely, EVAR has great results, and we are now presenting the fourteen-year results of the Zenith Flex AAA endograft, where we surveyed more than 600 patients treated in Perugia. We have published the article in the Journal of Surgery.

We found that it is a really reliable way of treating these patients, but still we have to think that we don’t halt the disease by inserting an endograft inside the AAA. We should look carefully for healthy zones in which to seal the graft to achieve very good long term results. But definitely for young patients, the minimally-invasive solution again is great tool because of the lesser risk of sexual impairment, easier recovery and easier return to daily life activities.

What do you see as the Achilles heel of EVAR and how can it be avoided?

That’s the question of the questions, because of course we have to fight against a disease that is not stopped with intervention. Probably the most important Achilles heel is the growing necks that usually, with time, are encountered in the follow up of patients.

First of all, looking for healthy necks is the mainstay of the therapy, which means sometimes extending beyond the limits of the standard abdominal aorta. Nowadays, we have a tool that is a fenestrated device in cases of short necks, as well as iliac branch devices downstream to deal with bad necks in the common iliacs. If we want to have positive, long-term results, we have to land in healthy necks from the beginning.

Nowadays we have the right solutions for most of the patients. We still treat 30% of our AAA patients with open repair. That means if the patient anatomy is not suitable and the patient is at good risk, he is usually addressed by open surgery. But most of the time, especially in patients with co-morbidities, we use a fenestrated device or an iliac branch device to deal with a short neck.

The other Achilles heel that up to now is not well addressed in my view is the type II endoleak. It is not probably a big deal in the first years after treatment, but if you look carefully, most of the patients with type IIs are encountering aneurysm growth with time, especially if the patients have to take oral anticoagulants during their getting older when cardiac disease is advancing. This therapy is often sustaining the type II endoleaks for a long time and the risk for an aneurysm growth and the loss of neck sealing due to shortening and widening of the sealing zone is increasing with time. We probably have to think about dealing with type II endoleaks from the beginning to have a solution that is fully durable during the entire life of the patient.

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Fabio Verzini, MD, PhD, is a paid consultant of Cook Medical.

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