title: Aortic rupture and sac expansion after endovascular repair of abdominal aortic aneurysm.
abstract: BACKGROUND
  Long-term concerns about the durability of endovascular aortic aneurysm repair (EVAR) remain after the publication of controlled trials. Increased expertise in endograft technology, case selection and postoperative reintervention has created a need for reappraisal of the longer-term efficacy of EVAR using contemporary data.
  
  
  METHODS
  Patients undergoing infrarenal EVAR between 2004 and 2010 were studied prospectively. Morphological compliance with manufacturers' instructions for use (IFU) was established using three-dimensional computed tomography. The primary outcome measures were all-cause and aneurysm-related mortality, postoperative rupture, reintervention and sac expansion. These adverse events were reported using Kaplan-Meier survival analysis, with comparison within, or outside IFU by the log rank test.
  
  
  RESULTS
  Some 478 patients of median age 76 years had a median aneurysm diameter of 62·9 mm. Median follow-up was 44 (range 11-94) months; 198 (41·4 per cent) were compliant with IFU. The 30-day mortality rate was 2·1 per cent (10 of 478 patients): nine (2·0 per cent) of 455 patients who had elective and one (4 per cent) of 23 patients who had non-elective surgery. Aneurysm-related mortality was 0·897 deaths per 100 person-years, and all-cause mortality was 8·558 deaths per 100 person-years, with significantly lower survival outside IFU (P = 0·012). Two patients had a late rupture (0·138 per 100 person-years), of whom one died. There were 6·120 reinterventions per 100 person-years, with no difference for aneurysms treated outside IFU (P = 0·136). Primary sac expansion occurred in 6·721 per 100 person-years and secondary sac expansion in 4·142 per 100 person-years.
  
  
  CONCLUSIONS
  In this series EVAR had a lower aneurysm-related mortality rate than demonstrated in early controlled trials, and with lower sac expansion rates than reported from image repositories. Data from earlier studies should be applied to current practice with caution.
authors.affiliation: Department of Outcomes Research, St George's Vascular Institute, St George's Healthcare NHS Trust, London, UK.
authors.forename: P J E
authors.initials: PJ
authors.lastname: Holt
authors.forename: A
authors.initials: A
authors.lastname: Karthikesalingam
authors.forename: B O
authors.initials: BO
authors.lastname: Patterson
authors.forename: T
authors.initials: T
authors.lastname: Ghatwary
authors.forename: R J
authors.initials: RJ
authors.lastname: Hinchliffe
authors.forename: I M
authors.initials: IM
authors.lastname: Loftus
authors.forename: M M
authors.initials: MM
authors.lastname: Thompson
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D017544:Aortic Aneurysm, Abdominal / Q000401:mortality / Q000601:surgery*; D001019:Aortic Rupture / Q000209:etiology* / Q000401:mortality / Q000601:surgery; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000401:mortality; D057510:Endovascular Procedures / Q000009:adverse effects* / Q000401:mortality; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000209:etiology / Q000473:pathology / Q000601:surgery; D011446:Prospective Studies; D012086:Reoperation