EVAR of AAA: Long term outcomes, disease progression and risk stratification

Background
Endovasvular aortic repair (EVAR) is the most commonly utilised technique for the treatment of abdominal aortic
aneurysms (AAA) in tertiary referral centers. Detailed long-term outcomes of this technique are relatively scarce,
especially for patients presenting symptomatically with AAA. Intra-operatively, proximal type Ia endoleak, involving
blood circulating into the AAA – due to poor proximal seal of the endograft to the aortic neck region – is a feared
complication which is usually promptly treated, given its association with post-operative AAA expansion and
rupture. Aneurysmatic disease is usually considered a progressive pathology with potential for progression to
areas of the aorta beyond the known aneurysmatic segment. Arterial calcifications are established as a marker for
atherosclerosis, yet the association of ilio-femoral calcification with post-operative mortality after EVAR is not
known.

Aims
1. Evaluate the long-term results of EVAR of AAA using a single endograft
2. Compare the early and late results of EVAR of symptomatically presenting patients to those treated asymptomatically
3. Study the long-term results of intra-operative treatment of type Ia endoleak using large, balloon expandable stents
4. Study the progression of aortic disease for patients treated with endovascular means in the postoperative period
5. Assess the novel ilio-femoral calcium score as a potential predictor for overall and cardiac-specific mortality after EVAR

Results
EVAR of AAA yields sustainable results in the long-term, for both symptomatic and asymptomatic patients. There
is ≈ x4 elevated early mortality in symptomatic patients as compared to asymptomatic ones. Intra-operative
treatment of type Ia endoleaks using large, balloon-expandable stents should be reserved to patients treated
acutely with EVAR. Aortic expansion beyond the sealing zone is relatively uncommon, and seems related to the
force exerted on the aortic wall by the endograft. Ilio-femoral calcium score may predict long-term overall and
cardiac mortality after EVAR, albeit the relation is weak. Therefore, further studies are needed to establish this
association.