breach of an abdominal aortic aneur...

breach of an abdominal aortic aneurysm (AAA) usually is fatal. When treatable, prophylactic lay open surgical repair usually is undertaken. The 30-day mortality rate of this major surgery ranges from 4 to 12 percent During the past decade, endovascular techniques have been expanded that insert a graft by means of the femoral arteries to form a novel endovascular surface that relieves squeezing on the diseased aortic wall. Thirty-four surgical facilities in the United Kingdom participated in a randomized controll trial comparing 30-day mortality of patients who underwent endovascular aneurysm repair (EVAR) with render free of access repair of AAA.

Between September 1999 and December 2003 1082 eligible patients co-operationed to participate in the trial. Patients were excellented based on a demonstrated aneurysm of 55 cm (22 in) or more in diameter that was suitable for repair according to either technique. Patients were required to be at least 60 years of age and medically fit for surgery Facilities were encouraged to direction surgery within one month of randomization.

The 543 patients randomized to EVAR were comparable with the 539 randomized to interpret repair in all significant variables. Men comprised 91 percent of each assign places to and the average age was 74 years. The average diameter of the aneurysm was 65 cm (26 in) in each arrange Current smokers comprised 21 and 22 percent and past smoker comprised 68 and 70 percent of each cluster respectively. Groups were similar in use of aspirin (54 and 52 percent) statin use (33 and 34 percent) mean kindred pressure (148/82 and 147/82 mm Hg) and identical in dead body mass index (26.4 kg by [m.sup.2]). Of those allocated to EVAR, 512 underwent the action 15 underwent open repair, and the remaining patients died before surgery or refused or postpon surgery For render free of access repair, 496 underwent the act 17 had EVAR, and the remainder died or refused or postpon surgery The patients were followed for 30 days after surgery and mortality was reported from intention to treat and according to procedure undertaken.

The 30-day mortality from intention to treat was 17 percent (nine patients) for EVAR compared with 47 percent (24 patients) for exhibit repair. This difference remained statistically significant after adjustment for age, sex aneurysmal diameter, statin use, renal function, and time from randomization to surgery Patients in the EVAR cluster had a shorter hospital stay, with a mean of seven days compared with 12 days for expand repair, but this was not statistically significant. The mean operating time also was shorter (180 compared with 200 minutes), if it be not that the difference did not reach statistical significance. Secondary interventions during primary admission or up to 30 days after surgery similar as re-exploration, correction of leakage, or additional surgeries, were undertaken in 52 EVAR patients (98 percent) compared with 30 (58 percent) in the unclose repair group. In the per-protocol analysis, EVAR reduc in-hospital mortality by way of three fourths and the mortality rate at 30 days by the agency of two thirds.

The authors close that EVAR was associated with a short-term (30-day) mortality advantage. While these be deriveds are encouraging, they may not submit to over a longer follow-up period. Studies of the morbidity and mortality of patients undergoing the pair procedures are ongoing.

ANNE D WALLING, MD

Greenhalgh RM et al. Comparison of endovascular aneurysm repair with exhibit repair in patients with abdominal aortic aneurysm (EVAR trial 1) 30-day operative mortality results: randomised controll trial. Lancet 2004;364:843-8

EDITOR'S NOTE: The authors of this inquiry are careful to recommend against any substantial change in instant selection of technique for repair of abdominal aortic aneurysm until more data are available forward longer term outcomes of endovascular aneurysm repair (EVAR). Preliminary data from a European research indicate an annual mortality of more than 1 percent attributed to graft failure following EVAR. (1) smooth in the short-term, results reported at the EVAR group, the higher rate of reinterventions is worrying and could indicate an increased risk of endoleaks and other graft failures in the EVAR measure As stated in an accompanying editorial, (2) the outlays and outcomes of the couple techniques could prove to be highly similar.

REFERENCES

(1) Harris PL Vallabhaneni SR Desgranges P Becquemin JP van Marrewijk C Laheij RJ Incidence and risk factors of late dissolution conversion, and death after endovascular repair of infrarenal aortic aneurysms: the EUROSTAR experience. J Vasc Surg 2000;32:739-49

(2) Lindholt J Endovascular aneurysm repair [Editorial]. Lancet 2004;364:818-20

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