A Decade of Experience with Endovascular Abdominal Aortic Aneurysm Repair (EVAR)
David C. Brewster, M.D., John E. Jones, MD*, Thomas K. Chung, MA*, Glenn M. LaMuraglia, MD*, Christopher J. Kwolek, MD*, Michael T. Watkins, MD*, Thomas M. Hodgman, BA*, Richard P. Cambria, MD
Massachusetts General Hospital, Boston, MA
OBJECTIVE(S): The proper role of endovascular abdominal aortic aneurysm repair (EVAR) remains controversial, largely due to uncertain late results. We reviewed a 10-year experience with EVAR to document late outcomes.
METHODS: During the interval 1/1/1994 to 6/1/2005, 905 patients underwent EVAR utilizing 10 different stent graft devices. Late outcomes were analyzed with multivariate methods from a pool of 640 patients with at least one-year follow-up.
RESULTS: Mean patient age was 75.6 years (44-99); 81.5% were male. Mean follow-up was 39.3 months. 17% of patients were considered unfit for open repair. On an intent-to-treat basis, device deployment was successful in 99.3%. 30-day mortality was 1.9%. By Kaplan-Meier analysis, freedom from AAA rupture was 97.9% at 5 years. Significant pre-operative risk factors for late AAA rupture included female gender ( [OR] = 16.8; p<0.012) and persistent endoleak ([OR] =33.2; p<0.015). Aneurysm related death was avoided in 96.1% of patients, with the need for any re-intervention ([OR]=33.8; p<0.007) and family history of aneurysmal disease ([OR]=180.5; p<0.019) among its most important predictors. 109 (13.7%) patients required re-intervention, with 77% of such procedures being catheter-based. Significant predictors of re-intervention included use of first- generation devices ([OR]=1.1; p<0.002)) and persistent endoleak ([OR]=3.7; p<0.0001). Currently employed second- and third- generation stent grafts correlated with improved outcomes. Cumulative freedom from conversion to open repair was 97.6% at 5 years. Cumulative survival was 52% at 5 years.
CONCLUSIONS: Based upon this decade of experience, EVAR using contemporary devices is a safe, effective, and durable method to prevent AAA rupture and aneurysm-related death. Assuming suitable AAA anatomy, these data justify a broad application of EVAR across a wide spectrum of patients.
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