AAA: Weighing Our Options
As we know all too well, the challenges of treating aortic disease are myriad and vary considerably from patient to patient. In each case, we evaluate for anatomic suitabilities, the patient’s lifestyle, preferences, and overall health, available therapeutic options, and our own abilities to effectively deliver the optimal therapy.
Even with 3 decades of experience developing, exploring, and applying endovascular aneurysm repair (EVAR) in the abdominal aorta, the questions of when, how, and in whom to intervene not only continue, but perhaps are currently seeing a resurgence in uncertainty and debate. Straightforward infrarenal cases still carry the now generational question of “open or endo?” while more challenging scenarios ask the same of us, with even less certain data to support either option.
In assembling this edition of Endovascular Today, we aimed to provide context for today’s challenging decisions, as well as some practical, expert opinions on how best to handle them. We have invited poignant discussions of key recent guidelines—those published by the European Society for Vascular Surgery (ESVS) and those just published as of press time by the United Kingdom’s National Institute for Health and Care Excellence (NICE) organization.
Countless hours of research, discussion, and deliberation have been undertaken in order to provide much-needed, ever-evolving guidance. To open our abdominal aortic aneurysm (AAA) feature, Anders Wanhainan, MD, provides key highlights from the recent update to the ESVS guidelines, in particular what has changed and why, and the potential effects on aortic practices.
It is not uncommon for new guidelines to be met with challenges and at times even vitriol. The draft recommendations from NICE, which were debated for nearly 2 years after initial circulation for comment, have certainly endured substantial scrutiny up to and including their publication in March 2020. This evolving story has shown us that the choice of the most appropriate treatment for AAA, especially in younger and otherwise healthy patients, is not a settled issue. We have asked Michael Jenkins, MBBS, to explain for a global audience how NICE guidance works, the particular challenges and controversies of arriving upon consensus within their framework, and the strengths and weaknesses of the data that shape them.
Aiming to meet specific anatomic needs with entirely endovascular approaches often involves some creativity, and matching device combinations can be tricky. We’ve asked several experts—Edward Y. Woo, MD; Sonia Ronchey, MD; and Kenneth Tran, MD, and Jason T. Lee, MD, to share their preferred options for parallel grafting and what works best in their hands.
Shifting gears from the podium to the OR, Sean Lyden, MD, summarizes where we currently stand with respect to EVAR fixation—which perhaps remains the greatest continual need for technologic advancement. Next, Darren B. Schneider, MD, explains how one might approach preparing an infrarenal landing zone in the setting of residual dissection.
Finally, Igor Koncar, MD, highlights the continued importance of maintaining open surgical proficiency for AAA repair, a skill set we cannot afford to lose or see compromised despite the popularity of endovascular repair.
Outside of our feature on AAA repair, Endovascular Today has also assembled an update on best practices for imaging and applications for superficial venous and lymphatic disease. This feature includes a tutorial on duplex ultrasound evaluation for lower extremity venous disease, and a wide-ranging expert panel on appropriate use and phlebolymphedema. Closing the edition is an insightful interview with Vlad Alexandrescu, MD.
As we finalize this issue of Endovascular Today, the world is confronting the effects of the novel COVID-19 strain of coronavirus. News of quarantines, illness, and the loss of life increasingly dominate the global health care landscape to an unprecedented degree in our lifetimes. We wish all of our colleagues and their families, friends, and patients the best of health and rapid recovery as we band together in our hospitals, communities, and homes.