title: Endovascular treatment for aortic disease: is a surgical environment necessary?
abstract: OBJECTIVE
  Interventional radiologists, cardiologists, and vascular surgeons are capable of performing endovascular procedures successfully in their respective environments. Suboptimal anatomy or intraoperative technical problems can be encountered, and endovascular management alone is not always suitable. The objectives of this study were to define the incidence of adjunctive surgical techniques, to discuss the rationale for endovascular reconstruction in a well-developed surgical environment, and to assess the effect of experience on the incidence of adjunctive repair.
  
  
  METHODS
  All primary aortic and aortoiliac elective, urgent, and emergent endovascular procedures performed at the Peter Lougheed Center and entered into a prospective database from May 25, 1999 to June 01, 2005, were reviewed. All adjunctive surgical techniques to enable stent deployment, enhance attachment site, or solve intraoperative difficulties were captured. The study period was divided into two time periods based on learning curve data to assess the effect of experience on the rate of adjunctive repairs.
  
  
  RESULTS
  Four hundred thirty-eight patients underwent elective (80%), urgent (15%), or emergent (5%) endovascular procedures during the study period. These consisted of 101 thoracic and 337 abdominal operations, including the use of 13 fenestrated stents. One hundred thirty-nine patients (31.7%) required 180 open surgical procedures. Complete data were available for the entire patient cohort. The mean follow-up was 793.2 days (SD, 519.1 days). Procedures were necessary for vascular access, arterial dissection/rupture, limb ischemia, and enhancement/elongation of the stent attachment site. The persistent endoleak rate was 5.3%, the late rupture rate was 0.7%, the conversion rate was 1.6%, the 30-day surgical mortality rate was 3.2%, all-cause mortality to date is 7.3%, and the reintervention rate was 4.6%. There was no statistically significant effect of the learning curve on the incidence of surgical adjunctive procedures in either the thoracic group (11/26 [42.3%] for phase 1 vs 17/75 [22.6%] for phase 2) or the abdominal group (14/50 [28.0%] for phase 1 vs 97/287 [33.8%] for phase 2). Overall, 31.5% of patients required adjunctive surgical repair.
  
  
  CONCLUSIONS
  Successful endografting requires endovascular expertise in addition to a well-developed surgical environment to increase applicability and decrease patient risk. Despite advances in endovascular technology, hybrid techniques will continue to be required to achieve good overall success rates.
authors.affiliation: Division of Vascular Surgery, Peter Lougheed Centre, University of Calgary, Alberta, Canada. RandyD.Moore@CalgaryHealthRegion.ca
authors.forename: Randy D
authors.initials: RD
authors.lastname: Moore
authors.forename: Laurencia
authors.initials: L
authors.lastname: Villalba
authors.forename: Paul F
authors.initials: PF
authors.lastname: Petrasek
authors.forename: Gregory
authors.initials: G
authors.lastname: Samis
authors.forename: Chad G
authors.initials: CG
authors.lastname: Ball
authors.forename: Mona
authors.initials: M
authors.lastname: Motamedi
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000416:Alberta; D017544:Aortic Aneurysm, Abdominal / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D017545:Aortic Aneurysm, Thoracic / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D001027:Aortography; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000379:methods*; D015331:Cohort Studies; D017558:Elective Surgical Procedures / Q000706:statistics & numerical data; D004638:Emergency Treatment / Q000706:statistics & numerical data; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D020380:Needs Assessment; D009873:Operating Rooms / Q000706:statistics & numerical data*; D011446:Prospective Studies; D011474:Prosthesis Design; D011475:Prosthesis Failure; D018570:Risk Assessment; D012720:Severity of Illness Index; D016019:Survival Analysis; D016896:Treatment Outcome