Over the past 20 years, the use of endografts has become the primary method of treatment for abdominal aortic aneurysms (AAAs). Yet, despite the widespread adoption of this technique, a number of questions regarding its application remain. Randomized trials have looked at outcomes with standard devices in well-defined settings, but even here, questions remain, and criticism of these studies as not reflecting current practice or technology cloud interpretation of long-term data. When these devices are utilized in challenging anatomic and clinical situations, the usefulness and applicability of endovascular aneurysm repair (EVAR) becomes even less clear.
Although there are significant perioperative risk reductions and benefits for EVAR in patients with AAAs, we have not completely defined risk-benefit ratios for this procedure in some of our most common clinical situations. With an understanding of the questions remaining regarding the use of these devices, in this issue, we look to explore the areas of uncertainty regarding the use of these devices to help readers better understand the limitations, unmet needs, areas of controversy, and potential opportunities for further research regarding one of the most significant advancements in the area of aneurysm repair.
Acknowledging our responsibility as treating clinicians to weigh all options—ranging from watchful waiting to EVAR to open repair—and knowledgeably discuss and present the alternatives to our patients, we have asked expert colleagues to address how best to weigh options across a variety of scenarios, mirroring many of the decisions we regularly have to make.
To start this issue, Graeme McFarland, MD, and Jason T. Lee, MD, highlight the anatomic variables associated with the compromised aortic neck and increased risk of proximal seal failure with standard EVAR. Next, Cornelis G. Vos, MD, and colleagues discuss nonfenestrated options for the treatment of AAAs with compromised necks, which is followed by a review of fenestrated options by Salma El Batti, MD, and colleagues.
Naiem Nassiri, MD; Alan Dardik, MD; Hence J.M. Verhagen, MD; Stéphan Haulon, MD; Claire Watkins, MD; Dominique Fabre, MD; and Gustavo S. Oderich, MD, tackle our Ask the Experts question of whether treating type II endoleak and the aneurysm sac makes a difference. Then, Nuno V. Dias, MD, and colleagues and Zachary M. Arthurs, MD, examine the utility of endovascular options and open repair in the setting of EVAR failure.
Prof. Jan Blankensteijn then addresses long-term outcomes of EVAR trials, comparing the results from the EVAR 1 and DREAM trials and discussing their impact for future investigations. To round out our EVAR coverage, Anders Wanhainen, MD, and colleagues review the roles of open and endovascular repair for treatment of primary and secondary aortic infections.
In this issue, you will also find a discussion of key developments in superficial venous disease by Raghu Kolluri, MD, and Brian Fowler, as well as a review of how to use existing data to predict and prevent varicose vein recurrence by Sergio Gianesini, MD. Then, a panel that includes Julianne Stoughton, MD; Thomas Proebstle, MD; Neil M. Khilnani, MD; and Steve Elias, MD, discusses the factors that drive platform adoption in superficial venous disease. In our featured interview, Daniela Branzan, MD, addresses technical aspects of thoracoabdominal aortic aneurysm repair, the importance of multidisciplinary cooperation, and advancements she hopes to see in the future.
Daniel G. Clair, MD
Timothy A. Resch, MD, PhD
Guest Chief Medical Editors