Endovascular repair of abdominal aortic aneurysms: current state and future expectations.
Masó Serra A; Artigas Soler A; Solanich Valldaura MT; Vallejo Tarrat A; Rosas Lario M; Zancajo Torrecillas JJ; Viader Barraca I.
Corporació Sanitària Parc Taulí. Sabadell, Barcelona.

Introduction
Abdominal aortic aneurysms (AAA) are a significant health issue and the cause of death in 1–3% of men over the age of 65 years in developed countries
Open aneurysm surgery, performed for over 50 years, has been considered the gold standard treatment. However, mortality rates remain high. In an attempt to lower this risk, less invasive endovascular aortic repair techniques were developed (EVAR). 
Fenestrated endovascular aneurysm repair (FEVAR) or branched EVAR (BEVAR) were initially developed to treat high-risk patients unfit for open surgery. Gradually these techniques have been used to treat a broader range of patients and are now considered first-line therapy for complex abdominal or thoracoabdominal aortic aneurysms in some experienced centers. 
But do these techniques success in providing less morbidity and mortality? Are we enough prepared to practice this treatment? No direct randomized trials to compare open surgery versus F/B-EVAR repair have been performed. The WINDOWS study published in 2015 was a multicenter prospective single-arm trial of F/B-EVAR for complex aortic aneurysms that had a mortality rate of 16,8% from postoperative days up to one month after surgery. 
We want to expose our experience in the management of these patients. 

Results
We collected data for all the F/B-EVAR performed from 2013 up to 2018 in our hospital. Of 30 patients (12 under 70 years old, 18 above 70 years old) we had a 16% mortality rate, one of them was during surgery. The deaths were thoracoabdominal aneurysms. 
Complications were present in a significant amount of patients. Acute renal failure was frequent with a 55% incidence. The impairment of the renal function has different origins. Intestinal and spinal cord ischemia were associated with the highest morbidity and mortality. 
The average days in hospital were 27. 

Discussion
Fenestrated and branched endovascular aneurysm repair (F/B-EVAR) has surpassed open repair and is now considered first-line therapy for complex AAA in many centres in response to several studies which showed promising results, with equal or even less perioperative mortality. Although EVAR is obviously less invasive than open surgical repair, it is not free of complications. 
These complications can potentially result in severe morbidity or even mortality, stressing the need for an exhaustive early detection and subsequent treatment. This includes surgical considerations, hospital resources, pre-operative optimization, the choice of anaesthetic technique, pharmacological protective strategies as well as a correct post-surgery care. 
New studies need to be done in order to see whether the benefits of F/B-EVAR techniques are transferable from specialized centers to the more general vascular community. 

References
(1)	Marzelle J, Presles E. “Results and Factors Affecting Early Outcome of Fenestrated and/or Branched Stent Grafts for Aortic Aneurysms: A Multicenter Prospective Study”. Annals of Surgery. 261(1):197–206, Jan 2015 
(2)	 Brinster CJ, Milner R. “Fenestrated endovascular aortic repair and clinical trial devices for complex abdominal aortic aneurysms. J Cardiovascular Surg (Torino),2018 Mar 19. 
(3)	Chaikof EL, Dalman RL. “The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm”. J Vasc Surg, Jan 2018.


06 / Endovascular repair of abdominal aortic aneurysms: current state and future expectations.