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ENDOVASCULAR REPAIR OFENDOVASCULAR REPAIR OF
RUPTURED ABDOMINALRUPTURED ABDOMINAL
AORTIC ANEURYSMSAORTIC ANEURYSMS
G. Trellopoulos
Clinic of Cardiovascular Surgery
General Hospital “G. Papanikolaou”, Thessaloniki
3ο
VASCULAR SYMPOSIUM
ADVANCES & CONTROVERSIES IN VASCULAR DISEASES
University of Thessaly
23-25 MAY 2008
Treatment of ruptured aortic aneurysmsTreatment of ruptured aortic aneurysms
BackgroundBackground
OOpenpen RRepairepair for rAAAfor rAAA representsrepresents::
High MortalityHigh Mortality 48.4%(25.4 –69.3)*48.4%(25.4 –69.3)*
High MorbidityHigh Morbidity 30-50%30-50%
*Bown MJ, Sutton AJ: Br J Surg 2002; 89:714-30.*Bown MJ, Sutton AJ: Br J Surg 2002; 89:714-30.
Treatment of ruptured aortic aneurysmsTreatment of ruptured aortic aneurysms
BackgroundBackground
ENDOVASCULAR REPAIRENDOVASCULAR REPAIR
Avoidance of general anesthesiaAvoidance of general anesthesia
Avoidance of aortic clamping and de-clampingAvoidance of aortic clamping and de-clamping
Less blood lossLess blood loss
Potential less Mortality and MorbidityPotential less Mortality and Morbidity
Treatment of ruptured aortic aneurysmsTreatment of ruptured aortic aneurysms
BackgroundBackground
The first reported e-EVAR...The first reported e-EVAR...
Lancet 344:1645, 1994
Treatment of ruptured aortic aneurysmsTreatment of ruptured aortic aneurysms
Studies and trialsStudies and trials
Since 2006, 28 studies
were published. A total of
857 patients with ruptured
AAA repaired with EVAR
Treatment of ruptured aortic aneurysmsTreatment of ruptured aortic aneurysms
Studies and trialsStudies and trials
Systematic Review
EVAREVAR
(n=148)(n=148)
OROR
(n=330)(n=330)
30 day30 day
mortalitymortality
22%22% 38%38%
SystemicSystemic
complicationscomplications
28%28% 56%56%
10 non RCT
Visser et al, Radiology,2007
E-EVARE-EVAR OROR
EarlyEarly
MortalityMortality
18%18% 34%34%
E-EVARE-EVAR
suitabilitysuitability
67% (34-67% (34-
100)100)
NaNa
Harkin et al, EJVES, 2007
33 non-RCT + 1 RCT (876 pts)
Between EVAR & OR :Heterogeneity was found in patients's hemodynamic
condition at their presence at the hospital
Treatment of ruptured aortic aneurysms
Literature Review
Randomized trials
Hinchliffe et al EJVES, 2006
E-EVARE-EVAR
n=15n=15
OROR
n=17n=17
P valueP value
30-day30-day
mortalitymortality
53%53% 53%53% NSNS
MorbidityMorbidity 77%77% 80%80% NSNS
Treatment of ruptured aortic aneurysms
An international multicenter study
EVAREVAR OROR
MortalityMortality 35%35% 39%39%
CTCT
examinationexamination
87%87% 87%87%
UnstableUnstable
patientpatient
43%43%
Time admisionTime admision
to operationto operation
90 min90 min 60min60min
Suitability for EVAR
52%
Hemodynamic
instability precluded
EVAR in 14%
The principal reason to
preclude EVAR was an
adverse configuration
of the neck
Peppelenboch N et al, J Vasc Surg 2006
Critical issues for successful EVAR
1.1. Clinical condition of patient (criteria)Clinical condition of patient (criteria)
2.2. CT imaging (anatomic criteria)CT imaging (anatomic criteria)
3.3. Type of anesthesiaType of anesthesia
4.4. Stent graft configurationStent graft configuration
5.5. Use of intraaortic occlusion balloonUse of intraaortic occlusion balloon
Critical issue ICritical issue I
Presentation of patient with ruptured AAAPresentation of patient with ruptured AAA
Which method is selected:Which method is selected:
Criteria and requirementsCriteria and requirements
EVAR?EVAR?
OR?OR?
Critical issue ICritical issue I
Clinical and anatomic criteriaClinical and anatomic criteria
Clinical criteriaClinical criteria
Stable patient >100mmHgStable patient >100mmHg
Moderate instabilityModerate instability
>60mmHg without episode>60mmHg without episode
of cardiac arestof cardiac arest
Severe instability <60mmHgSevere instability <60mmHg
with episode of loss ofwith episode of loss of
consciousnessconsciousness
Anatomic criteriaAnatomic criteria
Infrarenal neck: length > 10mmInfrarenal neck: length > 10mm
diameter < 32mmdiameter < 32mm
angulation < 85angulation < 8500
External iliac: diameter > 7mmExternal iliac: diameter > 7mm
Peppelenboch N et al, J Vasc Surg 2006; 43:1111-1122
A French group believes that the limit isA French group believes that the limit is 80mmHg80mmHg for cardiac, splahnic, renal and brainfor cardiac, splahnic, renal and brain
perfusionperfusion
Alsac JM et al, Acta Chir Belg 2005
The Monefiore group prefer even lower limitThe Monefiore group prefer even lower limit
atat 50mmHg50mmHg to gainto gain “hypotensive“hypotensive
hemostasis”hemostasis”
Veith FJ et al, JCardiovasc Surg 2002
Critical issue ICritical issue I
Requirements:Requirements:
appropriate training of medical andappropriate training of medical and
paramedical personnel, available in out-ofparamedical personnel, available in out-of
hours callhours call
availability of wide range of endograftsavailability of wide range of endografts
Our experience: EVAR is preferred when blood pressure is > 80mmHg
without loss of consciousness
Diameter of proximal neck: 29mm
Angulation of proximal neck: 400
Length of proximal neck: 8mm
Diameter of aneurysm: 7cm
Diameter of EIA: 11.5mm
Critical issue II – Anatomic criteriaCritical issue II – Anatomic criteria
Talent 34 x16x 155
Critical issue II – Anatomic criteriaCritical issue II – Anatomic criteria
Diameter of proximal neck: 25mm
Angulation of proximal neck: 750
Length of proximal neck: 20mm
Diameter of aneurysm: 9.9cm
Diameter of EIA: 10mm
Talent 30x16x155
Critical issue II – Anatomic criteriaCritical issue II – Anatomic criteria
Diameter of proximal neck: 22mm
Angulation of proximal neck: 900
Length of proximal neck: 12mm
Diameter of aneurysm: 11cm
Diameter of EIA: 9mm
Excluder 26x14x160
Critical issue II – Anatomic criteriaCritical issue II – Anatomic criteria
Diameter of proximal neck: 20mm
Angulation of proximal neck: 750
Length of proximal neck: 12mm
Diameter of aneurysm: 11,3cm
Diameter of EIA: 5mm
Critical issue IIICritical issue III
Type of anesthesiaType of anesthesia
One third of patients that are reported in theOne third of patients that are reported in the
literature have been operated under localliterature have been operated under local
anesthesiaanesthesia
26% started as local and were converted to26% started as local and were converted to
general anesthesiageneral anesthesia
Our experience: 62,5% of patients have been operated
under local anesthesia
Branchereau A et al, “Endovascular Aortic Repair: The state of the art”
Critical issue IV
Treatment of ruptured aortic aneurysms BF vs AUI
Anatomical and Technical requirements
1. Two healthy iliac access
2. More measurements
3. Contralateral cannulation
4. Bigger stock
5. Local anesthesia
1. One healthy iliac access
2. Less measurements
3. Fem-Fem bypass
4. Smaller Stock
5. General anesthesia
Critical issue IVCritical issue IV
Stent graft configurationStent graft configuration
Decision depends on:Decision depends on:
1.1. ExpertiseExpertise
2.2. AvailabilityAvailability
3.3. Anatomic characteristicsAnatomic characteristics
Bifurcated
45%
Aortouniiliac
52%
Our experience: 9/16 (56%): Bifurcated
3/16 (19%): Aortouniiliac
4/16: Other (2 proximal cuff, 1 iliac extender,
1 thoracic)
Branchereau A et al, “Endovascular
Aortic Repair: The state of the art”
Critical issue VCritical issue V
Use of intraaortic occlusion balloonUse of intraaortic occlusion balloon
10 centers10 centers  in hemodynamicallyin hemodynamically
unstable patientsunstable patients
7 centers7 centers  never used a balloonnever used a balloon
1 center1 center  always a balloon is usedalways a balloon is used
Branchereau A et al, “Endovascular Aortic Repair: The state of the art”
From 18 studies in 18 centers:From 18 studies in 18 centers:
Via branchial artery
(Montefiory group)
Via femoral artery (Malmo
group, Zurich group)
17% of 369 patients
required balloon occlusion
Our experience: in 2/16 (12.5%) cases an occlusion balloon was
used
30 day mortality30 day mortality
Veith et al reported a 30-day mortality in 18% (48 centers on
442 RAAAs)
Meta-analysis:
1. Harkin et al reported 18% mortality
2. Visser et al reported 22% mortality
Randomized trials:
Hinchliffe et al: 52% (EJVES, 2006)
International multicenter study:
Peppelenboch N et al: 35% (J Vasc Surg 2006)
Our experience: 37.5% in-hospital mortality (6/16)
30 day mortality30 day mortality
Explanations for different results:Explanations for different results:
1. The different percentage of suitability of EVAR in1. The different percentage of suitability of EVAR in
diverse centersdiverse centers
Greco G et al, J Vasc Surg 2006:Greco G et al, J Vasc Surg 2006: 6%6% patients with RAAA were repairedpatients with RAAA were repaired
EVARlyEVARly
Peppelenboch N et al, J Vasc Surg 2006: 52% patients with RAAA were
repaired EVARly
Dalainas et al, Word J Surg 2006: 93% patients with RAAA were repaired
EVARly
2. Operator’s experience
Greco G et al, J Vasc Surg 2006:Greco G et al, J Vasc Surg 2006:
centers with >25 cases / year, for 4
years (elective and nonelective)
mortality: 26%
centers with <25 cases / year
mortality: 46%
Follow-upFollow-up
Arya N et al, J Endovasc Ther 2004:Arya N et al, J Endovasc Ther 2004: 73%73% of patients demonstratedof patients demonstrated
significantly decreased (>5mm) diameter of aneurysm comparedsignificantly decreased (>5mm) diameter of aneurysm compared
with 43% elective serieswith 43% elective series
Hechelhammer L et al, J Vasc Surg 2005: The risk of secondaryHechelhammer L et al, J Vasc Surg 2005: The risk of secondary
interventions in 2 years isinterventions in 2 years is 35%.35%. Late conversionLate conversion 9%9%
Visser JJ et al, J Vasc Surg 2006: Mortality and complications wasVisser JJ et al, J Vasc Surg 2006: Mortality and complications was
similar in patientssimilar in patients after endovascular repair compared with thoseafter endovascular repair compared with those
after open surgeryafter open surgery
Our experience: in meanly 2-years follow-up 2/10 survivors presented with
proximal migration. The one was treated endovascularly and the other with
open surgery. One patient died due to myocardiac infraction.
Preoperative: 25mm 1 year: 28mm 4 years: 28mm
Preoperative: 9,9cm 1 year: 6,8cm 4 years: 6,5cm
Preoperative: 25mm After 6 months: 27mm 2 years: 27mm
Preoperative: 9cm After 6 months: 7.5mm 2 years: 7.5cm
Preoperative: 28mm 1 year: 28mm 2 years: 28mm
Preoperative: 8cm 1 year: 6,1cm 2 years: 5cm
Conclusions
1.1. EVAR for RAAA is feasible in selected patientsEVAR for RAAA is feasible in selected patients
in institution with experiencein institution with experience
2.2. The mortality after EVAR for RAAA isThe mortality after EVAR for RAAA is
influenced from operator’s experience and theinfluenced from operator’s experience and the
“suitability of patients” in different centers“suitability of patients” in different centers
3.3. The risk of reintervention after EVAR is highThe risk of reintervention after EVAR is high
and strict follow-up is necessaryand strict follow-up is necessary
4.4. Long term data are needed to assist if EVAR isLong term data are needed to assist if EVAR is
durable treatment in relation to Endoleak anddurable treatment in relation to Endoleak and
ruptured risk.ruptured risk.
5.5. The debate for the future would be not whichThe debate for the future would be not which
technique is superior, but to define exactly thetechnique is superior, but to define exactly the
role of endovascular repair as an additionalrole of endovascular repair as an additional
therapeutic option for RAAAs.therapeutic option for RAAAs.
EFKARISTO!

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Endovascular repair of traumatic aortic transection six years of experience

  • 1. ENDOVASCULAR REPAIR OFENDOVASCULAR REPAIR OF RUPTURED ABDOMINALRUPTURED ABDOMINAL AORTIC ANEURYSMSAORTIC ANEURYSMS G. Trellopoulos Clinic of Cardiovascular Surgery General Hospital “G. Papanikolaou”, Thessaloniki 3ο VASCULAR SYMPOSIUM ADVANCES & CONTROVERSIES IN VASCULAR DISEASES University of Thessaly 23-25 MAY 2008
  • 2. Treatment of ruptured aortic aneurysmsTreatment of ruptured aortic aneurysms BackgroundBackground OOpenpen RRepairepair for rAAAfor rAAA representsrepresents:: High MortalityHigh Mortality 48.4%(25.4 –69.3)*48.4%(25.4 –69.3)* High MorbidityHigh Morbidity 30-50%30-50% *Bown MJ, Sutton AJ: Br J Surg 2002; 89:714-30.*Bown MJ, Sutton AJ: Br J Surg 2002; 89:714-30.
  • 3. Treatment of ruptured aortic aneurysmsTreatment of ruptured aortic aneurysms BackgroundBackground ENDOVASCULAR REPAIRENDOVASCULAR REPAIR Avoidance of general anesthesiaAvoidance of general anesthesia Avoidance of aortic clamping and de-clampingAvoidance of aortic clamping and de-clamping Less blood lossLess blood loss Potential less Mortality and MorbidityPotential less Mortality and Morbidity
  • 4. Treatment of ruptured aortic aneurysmsTreatment of ruptured aortic aneurysms BackgroundBackground The first reported e-EVAR...The first reported e-EVAR... Lancet 344:1645, 1994
  • 5. Treatment of ruptured aortic aneurysmsTreatment of ruptured aortic aneurysms Studies and trialsStudies and trials Since 2006, 28 studies were published. A total of 857 patients with ruptured AAA repaired with EVAR
  • 6. Treatment of ruptured aortic aneurysmsTreatment of ruptured aortic aneurysms Studies and trialsStudies and trials Systematic Review EVAREVAR (n=148)(n=148) OROR (n=330)(n=330) 30 day30 day mortalitymortality 22%22% 38%38% SystemicSystemic complicationscomplications 28%28% 56%56% 10 non RCT Visser et al, Radiology,2007 E-EVARE-EVAR OROR EarlyEarly MortalityMortality 18%18% 34%34% E-EVARE-EVAR suitabilitysuitability 67% (34-67% (34- 100)100) NaNa Harkin et al, EJVES, 2007 33 non-RCT + 1 RCT (876 pts) Between EVAR & OR :Heterogeneity was found in patients's hemodynamic condition at their presence at the hospital
  • 7. Treatment of ruptured aortic aneurysms Literature Review Randomized trials Hinchliffe et al EJVES, 2006 E-EVARE-EVAR n=15n=15 OROR n=17n=17 P valueP value 30-day30-day mortalitymortality 53%53% 53%53% NSNS MorbidityMorbidity 77%77% 80%80% NSNS
  • 8. Treatment of ruptured aortic aneurysms An international multicenter study EVAREVAR OROR MortalityMortality 35%35% 39%39% CTCT examinationexamination 87%87% 87%87% UnstableUnstable patientpatient 43%43% Time admisionTime admision to operationto operation 90 min90 min 60min60min Suitability for EVAR 52% Hemodynamic instability precluded EVAR in 14% The principal reason to preclude EVAR was an adverse configuration of the neck Peppelenboch N et al, J Vasc Surg 2006
  • 9. Critical issues for successful EVAR 1.1. Clinical condition of patient (criteria)Clinical condition of patient (criteria) 2.2. CT imaging (anatomic criteria)CT imaging (anatomic criteria) 3.3. Type of anesthesiaType of anesthesia 4.4. Stent graft configurationStent graft configuration 5.5. Use of intraaortic occlusion balloonUse of intraaortic occlusion balloon
  • 10. Critical issue ICritical issue I Presentation of patient with ruptured AAAPresentation of patient with ruptured AAA Which method is selected:Which method is selected: Criteria and requirementsCriteria and requirements EVAR?EVAR? OR?OR?
  • 11. Critical issue ICritical issue I Clinical and anatomic criteriaClinical and anatomic criteria Clinical criteriaClinical criteria Stable patient >100mmHgStable patient >100mmHg Moderate instabilityModerate instability >60mmHg without episode>60mmHg without episode of cardiac arestof cardiac arest Severe instability <60mmHgSevere instability <60mmHg with episode of loss ofwith episode of loss of consciousnessconsciousness Anatomic criteriaAnatomic criteria Infrarenal neck: length > 10mmInfrarenal neck: length > 10mm diameter < 32mmdiameter < 32mm angulation < 85angulation < 8500 External iliac: diameter > 7mmExternal iliac: diameter > 7mm Peppelenboch N et al, J Vasc Surg 2006; 43:1111-1122 A French group believes that the limit isA French group believes that the limit is 80mmHg80mmHg for cardiac, splahnic, renal and brainfor cardiac, splahnic, renal and brain perfusionperfusion Alsac JM et al, Acta Chir Belg 2005 The Monefiore group prefer even lower limitThe Monefiore group prefer even lower limit atat 50mmHg50mmHg to gainto gain “hypotensive“hypotensive hemostasis”hemostasis” Veith FJ et al, JCardiovasc Surg 2002
  • 12. Critical issue ICritical issue I Requirements:Requirements: appropriate training of medical andappropriate training of medical and paramedical personnel, available in out-ofparamedical personnel, available in out-of hours callhours call availability of wide range of endograftsavailability of wide range of endografts Our experience: EVAR is preferred when blood pressure is > 80mmHg without loss of consciousness
  • 13. Diameter of proximal neck: 29mm Angulation of proximal neck: 400 Length of proximal neck: 8mm Diameter of aneurysm: 7cm Diameter of EIA: 11.5mm Critical issue II – Anatomic criteriaCritical issue II – Anatomic criteria Talent 34 x16x 155
  • 14. Critical issue II – Anatomic criteriaCritical issue II – Anatomic criteria Diameter of proximal neck: 25mm Angulation of proximal neck: 750 Length of proximal neck: 20mm Diameter of aneurysm: 9.9cm Diameter of EIA: 10mm Talent 30x16x155
  • 15. Critical issue II – Anatomic criteriaCritical issue II – Anatomic criteria Diameter of proximal neck: 22mm Angulation of proximal neck: 900 Length of proximal neck: 12mm Diameter of aneurysm: 11cm Diameter of EIA: 9mm Excluder 26x14x160
  • 16. Critical issue II – Anatomic criteriaCritical issue II – Anatomic criteria Diameter of proximal neck: 20mm Angulation of proximal neck: 750 Length of proximal neck: 12mm Diameter of aneurysm: 11,3cm Diameter of EIA: 5mm
  • 17. Critical issue IIICritical issue III Type of anesthesiaType of anesthesia One third of patients that are reported in theOne third of patients that are reported in the literature have been operated under localliterature have been operated under local anesthesiaanesthesia 26% started as local and were converted to26% started as local and were converted to general anesthesiageneral anesthesia Our experience: 62,5% of patients have been operated under local anesthesia Branchereau A et al, “Endovascular Aortic Repair: The state of the art”
  • 18. Critical issue IV Treatment of ruptured aortic aneurysms BF vs AUI Anatomical and Technical requirements 1. Two healthy iliac access 2. More measurements 3. Contralateral cannulation 4. Bigger stock 5. Local anesthesia 1. One healthy iliac access 2. Less measurements 3. Fem-Fem bypass 4. Smaller Stock 5. General anesthesia
  • 19. Critical issue IVCritical issue IV Stent graft configurationStent graft configuration Decision depends on:Decision depends on: 1.1. ExpertiseExpertise 2.2. AvailabilityAvailability 3.3. Anatomic characteristicsAnatomic characteristics Bifurcated 45% Aortouniiliac 52% Our experience: 9/16 (56%): Bifurcated 3/16 (19%): Aortouniiliac 4/16: Other (2 proximal cuff, 1 iliac extender, 1 thoracic) Branchereau A et al, “Endovascular Aortic Repair: The state of the art”
  • 20. Critical issue VCritical issue V Use of intraaortic occlusion balloonUse of intraaortic occlusion balloon 10 centers10 centers  in hemodynamicallyin hemodynamically unstable patientsunstable patients 7 centers7 centers  never used a balloonnever used a balloon 1 center1 center  always a balloon is usedalways a balloon is used Branchereau A et al, “Endovascular Aortic Repair: The state of the art” From 18 studies in 18 centers:From 18 studies in 18 centers: Via branchial artery (Montefiory group) Via femoral artery (Malmo group, Zurich group) 17% of 369 patients required balloon occlusion Our experience: in 2/16 (12.5%) cases an occlusion balloon was used
  • 21. 30 day mortality30 day mortality Veith et al reported a 30-day mortality in 18% (48 centers on 442 RAAAs) Meta-analysis: 1. Harkin et al reported 18% mortality 2. Visser et al reported 22% mortality Randomized trials: Hinchliffe et al: 52% (EJVES, 2006) International multicenter study: Peppelenboch N et al: 35% (J Vasc Surg 2006) Our experience: 37.5% in-hospital mortality (6/16)
  • 22. 30 day mortality30 day mortality Explanations for different results:Explanations for different results: 1. The different percentage of suitability of EVAR in1. The different percentage of suitability of EVAR in diverse centersdiverse centers Greco G et al, J Vasc Surg 2006:Greco G et al, J Vasc Surg 2006: 6%6% patients with RAAA were repairedpatients with RAAA were repaired EVARlyEVARly Peppelenboch N et al, J Vasc Surg 2006: 52% patients with RAAA were repaired EVARly Dalainas et al, Word J Surg 2006: 93% patients with RAAA were repaired EVARly 2. Operator’s experience Greco G et al, J Vasc Surg 2006:Greco G et al, J Vasc Surg 2006: centers with >25 cases / year, for 4 years (elective and nonelective) mortality: 26% centers with <25 cases / year mortality: 46%
  • 23. Follow-upFollow-up Arya N et al, J Endovasc Ther 2004:Arya N et al, J Endovasc Ther 2004: 73%73% of patients demonstratedof patients demonstrated significantly decreased (>5mm) diameter of aneurysm comparedsignificantly decreased (>5mm) diameter of aneurysm compared with 43% elective serieswith 43% elective series Hechelhammer L et al, J Vasc Surg 2005: The risk of secondaryHechelhammer L et al, J Vasc Surg 2005: The risk of secondary interventions in 2 years isinterventions in 2 years is 35%.35%. Late conversionLate conversion 9%9% Visser JJ et al, J Vasc Surg 2006: Mortality and complications wasVisser JJ et al, J Vasc Surg 2006: Mortality and complications was similar in patientssimilar in patients after endovascular repair compared with thoseafter endovascular repair compared with those after open surgeryafter open surgery Our experience: in meanly 2-years follow-up 2/10 survivors presented with proximal migration. The one was treated endovascularly and the other with open surgery. One patient died due to myocardiac infraction.
  • 24. Preoperative: 25mm 1 year: 28mm 4 years: 28mm Preoperative: 9,9cm 1 year: 6,8cm 4 years: 6,5cm
  • 25. Preoperative: 25mm After 6 months: 27mm 2 years: 27mm Preoperative: 9cm After 6 months: 7.5mm 2 years: 7.5cm
  • 26. Preoperative: 28mm 1 year: 28mm 2 years: 28mm Preoperative: 8cm 1 year: 6,1cm 2 years: 5cm
  • 27. Conclusions 1.1. EVAR for RAAA is feasible in selected patientsEVAR for RAAA is feasible in selected patients in institution with experiencein institution with experience 2.2. The mortality after EVAR for RAAA isThe mortality after EVAR for RAAA is influenced from operator’s experience and theinfluenced from operator’s experience and the “suitability of patients” in different centers“suitability of patients” in different centers 3.3. The risk of reintervention after EVAR is highThe risk of reintervention after EVAR is high and strict follow-up is necessaryand strict follow-up is necessary 4.4. Long term data are needed to assist if EVAR isLong term data are needed to assist if EVAR is durable treatment in relation to Endoleak anddurable treatment in relation to Endoleak and ruptured risk.ruptured risk. 5.5. The debate for the future would be not whichThe debate for the future would be not which technique is superior, but to define exactly thetechnique is superior, but to define exactly the role of endovascular repair as an additionalrole of endovascular repair as an additional therapeutic option for RAAAs.therapeutic option for RAAAs.

Editor's Notes

  1. ?