title: Are concerns about EVAR durability relevant with modern devices?
abstract: Endovascular aneurysm repair (EVAR) is now universally adopted as first-line therapy for the management of large abdominal aortic aneurysms (AAA). The applicability has broadened such that up to 80% of patients are morphologically suitable for EVAR. In-spite of the evidence base demonstrating improved early outcomes following EVAR compared to open surgery, and informed patients' preference, EVAR-sceptics remain. The doubters voice anxieties regarding the durability of an endovascular repair and cite evidence of graft failures from the EVAR-1 trial results. Historically, graft migration and endoleak development have been the Achilles heel of EVAR. However, EVAR is an evolving technology that over the last 10 years has seen significant development from industry, and greater experience among clinicians. This has combined with centralisation of expertise in larger vascular units, with increased case-volume, leading to more appropriate periprocedural and long-term care. Current devices offer a durable repair for patients with infra-renal aortic aneurysms. The risk of graft migration is minimised by devices with secure fixation systems, potentially limiting de-novo type 1 and 3 endoleaks. Appropriate surveillance and timely endovascular re-interventions are perhaps the most important factors to ensure robust long-term outcomes from endovascular repair, even when native vessel morphology changes. Industry registry evidence and large single unit case series are now generating a healthy evidence base of EVAR durability in contemporary endovascular practice, that affirms its role as first-line therapy in the majority of morphologically suitable patients.
authors.affiliation: Department of Vascular Surgery, University Hospital Southampton, Tremona road, Southampton, UK. ian.nordon@uhs.nhs.uk
authors.forename: I M
authors.initials: IM
authors.lastname: Nordon
authors.forename: M M
authors.initials: MM
authors.lastname: Thompson
authors.forename: I M
authors.initials: IM
authors.lastname: Loftus
mesh_terms: D017544:Aortic Aneurysm, Abdominal / Q000473:pathology / Q000601:surgery*; D001807:Blood Vessel Prosthesis; D057867:Endoleak; D057510:Endovascular Procedures / Q000009:adverse effects / Q000295:instrumentation*; D005548:Foreign-Body Migration; D006801:Humans; D011475:Prosthesis Failure; D015607:Stents