Evolutionary Milestones

By Takao Ohki, MD, PhD, Chief Medical Editor

Seven years after the FDA first approved an endovascular stent graft for the treatment of abdominal aortic aneurysms (AAAs), we are performing the procedure with increasing frequency and fervor. It is estimated that of the 60,000 AAAs treated each year in the US, nearly 50% are treated endovascularly. Whereas some medical devices and procedures come in a flash and are gone just as fast, endovascular aneurysm repair (EVAR) has continued to build momentum and solidify its place in the treatment of vascular disease.

EVAR has endured intense scrutiny (even a severe blow from the US Department of Justice), and the procedure will continue to be under the microscope as the early trials enter their respective long-term follow-up stages. But new device designs continue to emerge, with many exciting European and US regulatory trials underway. Promising technologies include lower-profile devices that will allow percutaneous delivery and endostapling devices that provide increased durability as well as the ability to treat short, angulated necks. The continued development of new EVAR devices, despite setbacks with some of the previous designs, is in part because the enthusiasm surrounding EVAR is not just coming from physicians; an increasing number of patients say they have no interest in undergoing open surgery and demand the less-invasive procedure. It's hard to blame them. On the surface, it is easy to see that EVAR offers shorter hospital stays, a procedure that is much easier on the patient while on the table and in the recovery period, and low complication rates that continue to be impressive.

Perhaps the biggest news in EVAR this year is the passing into law of the SAAAVE Act, which provides a one-time screening for select new Medicare beneficiaries. This landmark legislation was pushed through Congress with the steadfast dedication of physicians and supporting senators and representatives, to whom we are deeply indebted. In this issue of Endovascular Today, we are proud to feature an interview with Dr. Robert M. Zwolak, who spearheaded this challenging project. Thank you, Bob!

With this legislation and the increasing demand for EVAR, many physicians will be performing more EVAR procedures. To highlight this trend, E. Bruce McIff, MD, et al have submitted an article on their experiences performing EVAR in a community hospital setting. We are also pleased to have an article by my fellow Chief Medical Editor, Barry T. Katzen, MD, et al, demonstrating their experiences treating AAAs with short proximal aortic necks, an anatomical presentation we could all benefit from understanding better as the patient base expands.

Imaging modalities related to EVAR have also shown improvement, with CT, MR, and ultrasound systems providing us with accuracy for our screening, procedural, and postprocedural surveillance needs. Ali AbuRahma, MD, et al have explored the benefits of CT versus duplex ultrasound surveillance after EVAR, and we are happy to share their findings in this issue. Regarding improvements to device design, Zvonimir Krajcer, MD, et al present their very interesting work in developing a novel way of designing endografts using mathematical modeling. Another article on the impact of device design is provided by Dieter Raithel, MD, PhD, et al, discussing the concept of anatomical fixation. Finally, Evan C. Lipsitz, MD, and I have provided an article on late conversion to open repair; something that we may be doing more often with longer follow-up. Please also see our comprehensive charts displaying all the relevant information pertaining to AAA devices and accessories, which can be found on pages 64-65 and 72-73.

Another major development is the possible approval of EVAR in Japan, as the Gore Excluder and Cook Zenith devices are expected to receive "Shonin" this year. It is hard to believe, but the second largest economy in the world and such a technology-savvy country is still performing EVAR with homemade devices, something that we abandoned (almost completely) 7 years ago after FDA approval of an endograft. I would also like to welcome Drs. Yoshiaki Yokoi and Hiroyoshi Yokoi from Japan to our International Editorial Board. Both are true pioneers of peripheral intervention in Japan, and we will all benefit from their experience.

I hope you find these articles as interesting and useful as we do, and I thank the authors for their contributions.


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About Endovascular Today

Endovascular Today is a publication dedicated to bringing you comprehensive coverage of all the latest technology, techniques, and developments in the endovascular field. Our Editorial Advisory Board is composed of the top endovascular specialists, including interventional cardiologists, interventional radiologists, vascular surgeons, neurologists, and vascular medicine practitioners, and our publication is read by an audience of more than 22,000 members of the endovascular community.