Authors' objectives:

This review assesses the evidence on the endovascular repair of abdominal aortic aneurysm.

The questions were : - Is endovascular abdominal aortic aneurysm repair (EVAR) safe, effective and cost-effective in repairing abdominal aortic aneurysms compared with open surgical repair? - What are the indications and contraindications for EVAR?

Authors' results and conclusions: Safety and Effectiveness: - The success rates of performing EVAR in eligible patients are high (81 per cent-100 per cent, median 97 per cent) and comparable to those of open surgical repair (OSR). - Technical success (complete exclusion of the aneurysm from blood circulation) rates of EVAR (62 per cent-98 per cent, median 83.5 per cent) is reduced because of high rates of initial endoleak (failure of the graft to exclude blood flow into the aneurysm) in EVAR. - Mortality rates within 30 days following EVAR (0-8.5 per cent, median two per cent) are comparable to those of elective open surgical repairs (0-6 per cent, median 4 per cent). Patients with high surgical risks may have higher mortality (up to 18 per cent) and morbidity rates. - Fluctuations in blood flow are less severe and there is a lower chance of poor blood supply to certain parts of the body during EVAR than during OSR. - EVAR has been associated with less blood transfusion and shorter stay in the intensive care unit and hospital compared to OSR Concerns regarding EVAR: - A median of three per cent of patients that underwent EVAR was required to convert to open surgical repair because of failure of EVAR. The risk of death from conversion to open surgical repair in patients unfit for open surgery could be as high as 66 per cent. - A significant percentage of patients required additional procedures to correct endoleaks, shifting of the graft, device failure and undesired blockage of other arteries by the graft. Most of these do not involve open surgical procedures. - With longer followed-up, the incidence of late endoleaks, late ruptures and device failures were reported. The significance of persistent and late endoleaks is not well understood. Indications for EVAR - The selection of candidates for EVAR is based mainly on the anatomy of the aneurysm. - Advanced age and co-existing diseases were associated with increased risk of complications immediately following EVAR. - Patients with poor medical conditions who were not fit for anesthesia and/or open surgical repair were shown to have significantly higher mortality after - EVAR compared with patients fit for open surgical repair (up to 18 per cent). - Patients with AAA in whom surgical repair is not recommended because of problems such as scar tissues inside the abdomen, inflamed aneurysm or gross obesity but who are otherwise fit were identified as suitable candidates for EVAR. - A high quality study in the United Kingdom has shown that for small AAA (4.0 - 5.5 cm), early elective open surgical repair did not provide long-term survival advantage over monitoring using ultrasound at 6-month intervals.

Authors' recommendations: - Endovascular aneurysm repair is an adjunctive technology rather than a replacement technology to open surgical repair. - No definitive conclusion regarding the long-term effectiveness or cost-effectiveness of EVAR can be drawn. - There is insufficient quality evidence to support the use of EVAR in patients with small aneurysms or in those who are fit for open surgical aneurysm repair. - EVAR may be appropriate for treating AAAs in a small subset of patients who are unfit for surgical repair (high risk) and whose risk of aneurysm rupture outweighs the risk of dying from EVAR. - Long-term follow-up is required following EVAR. - There is potential for over-utilization of EVAR in patients with marginal indications.

Authors' methods: Systematic review

Project Status: Completed

Year Published: 2002

URL for published report: http://www.health.gov.on.ca/english/providers/program/mas/tech/reviews/pdf/rev_evar_030102.pdf

URL for additional information: http://www.hqontario.ca/evidence/publications-and-ohtac-recommendations/ohtas-reports-and-ohtac-recommendations/endovascular-repair-of-abdominal-aortic-aneurysms

English language abstract: An English language summary is available

Publication Type: Not Assigned

Country: Canada

Organisation Name: Medical Advisory Secretariat

Contact Address: Medical Advisory Secretariat, 20 Dundas Street West, 10th Floor, Toronto, ON M5G 2N6 CANADA. Tel: 416-314-1092l; Fax: 416-325-2364;

Contact Name: MASinfo.moh@ontario.ca

Contact Email: MASinfo.moh@ontario.ca

Copyright: Medical Advisory Secretariat, Ontario Ministry of Health and Long-Term Care