Chief Medical Editor's Page
Endovascular Treatment of AAAs
Abdominal aortic aneurysms (AAAs) kill approximately 15,000 Americans each year. They are the third leading cause of sudden death in men over 60, and the 13th leading cause of death overall. Open surgical repair has been the gold standard of AAA treatment since Charles Dubost, MD, reported the first procedure in 1951. This approach requires a major laparotomy and several months of recovery; an estimated 50,000 such surgeries are performed in the US each year and the number continues to grow. Although surgical repair is lifesaving and durable, the procedure has a number of downsides that largely relate to the invasive nature of the treatment.
In 1990, Juan Carlos Parodi, MD, introduced a new approach to AAA repair. For a long time, he had entertained the idea of treating AAAs by inserting a graft secured by a metallic stent from a remote access site, thereby eliminating the need for laparotomy. Dr. Parodi’s efforts took him from the laboratory to a clinical setting when he was faced with a patient who had a large AAA but was too sick to undergo surgical repair. Out of desperation, Dr. Parodi executed his long-incubated idea. He submitted a manuscript reporting this experience to the Journal of Vascular Surgery, but it was rejected. The report was later published in another journal; this landmark article has since become the most frequently quoted vascular piece of the last decade. Without a doubt, Dr. Parodi was a surgeon ahead of his time.
Since the birth of this new field, endovascular aneurysm repair (EVAR) has survived the expected media blitz touting unrealistic benefits and successes. EVAR has also weathered a hailstorm of backlash media coverage. A recent article in USAToday entitled “Debate follows development of medical device: Smaller incision cuts recovery time, but durability questioned” (September 24, 2002), as well as several other major articles, have pointed to the dark side of EVAR, notably citing the procedure’s supposed poor long-term durability. EVAR has also been attacked from within the medical community. A recent editorial in the British Journal of Surgery by Collin et al concluded that EVAR is “a failed experiment.” The authors stated that, “the gestation period of experimental EVAR has already been 10 years. Induction is long overdue. When eventually delivered, it will probably be stillborn. We believe it is dead already.”
Actually, EVAR is already—or still—in its infancy. It is too soon to draw any firm conclusions, especially regarding patients who may be good candidates for both open surgical repair and EVAR. The ongoing British trial comparing EVAR to surgery and conservative therapy (UK EVAR I and II) will shed light on this important issue. It is already clear, however, that endograft technology has saved the lives of thousands of patients who could not have been treated surgically. Dr. Parodi developed EVAR because there was a need for an alternative treatment. The first patient underwent EVAR 12 years ago and survived until 8 years postprocedure—when he died of a heart attack.
This issue of Endovascular Today highlights various topics surrounding EVAR, including ideal imaging techniques and the modes of endograft failure, as well as what we can expect from surgical therapy. The EVAR field is evolving rapidly, as proven by the introduction of newer and hopefully better endografts, as well as by the development of peripheral devices such as implantable wireless pressure sensors. Endovascular Today will also cover these future changes.
In closing, I would like to dedicate this issue to Juan Carlos Parodi, MD. Thanks to Dr. Parodi, there has never been a more exciting time to be a vascular therapist.