title: Mini-invasive treatment of abdominal aortic aneurysms: current roles of endovascular, laparoscopic, and open techniques.
abstract: BACKGROUND
  Endovascular aortic repair (EVAR), laparoscopic aortic surgery (LAS), and open surgery (OS) are three established treatment methods of abdominal aortic aneurysms (AAA). While these techniques are often percieved as competitive between them, they are complementary for the vascular surgeon, whose goal is to provide a treatment adapted to each case that is noninvasive and durable. The objective of this study was to report our results of AAA repair to better define the roles of the three techniques.
  
  
  METHODS
  From January 2009 to December 2011, we operated on 235 patients for AAAs. Patients for whom the three technical methods were discussed preoperatively were selected. Cases where the three techniques were not discussed were excluded (ruptured AAA, technique not available). One hundred seventy-five (75%) patients were included. Four groups were established based on the surgical risk and the anatomic EVAR criteria of the French Health Authority (Haute Autorité de Santé [HAS]), including: (1) good risk and favorable anatomy (GR-FA); (2) good risk and unfavorable anatomy (GR-UA); (3) high-risk and favorable anatomy (HR-FA); and (4) high-risk and unfavorable anatomy (HR-UA). Data collection was prospective. The numerical data were expressed as median and range.
  
  
  RESULTS
  There were 166 (95%) men, aged 74 years (range 38-97 years). AAA diameter was 51 mm (range 30-81 mm). Mini-invasive treatment (EVAR or LAS) was chosen in 156 (89%) cases. Mortality at 30 days was 3.4% (6 patients, 1 EVAR, 1 LAS, and 4 OS), including 3 patients presenting with a "shaggy aorta." There were 58, 19, 65, and 33 patients in groups GR-FA (33%), GR-UA (11%), HR-FA (37%), and HR-UA (19%), respectively. The distribution of the three techniques (EVAR, LAS, OS) according to the groups was as follows: GR-FA (9, 46, 3); GR-UA (0, 13, 6); HR-FA (50, 13, 2); and HR-UA (12, 13, 8), respectively. The results by subgroups are presented.
  
  
  CONCLUSIONS
  Based on our results, we present a new algorithm for AAA treatment. Among GR-FA patients, EVAR and LAS should be discussed according to life expectancy and wish of the patient. In GR-UA patients, LAS and OS can be proposed. For HR-FA patients, EVAR remains the first choice, but LAS can be used in cases with good life expectancy. In the HR-UA patients, LAS is the best choice because of the late complications of EVAR, but a broader use of fenestrated stent grafts or the chimney technique may be beneficial. Last, the surgical threshold should be pushed back among AAA patients presenting with a shaggy aorta.
authors.affiliation: Service de Chirurgie Vasculaire, Hôpital Universitaire Ambroise Paré, Boulogne-Billancourt, et Faculté de Médecine Paris-Ile de France-Ouest, Université de Versailles Saint Quentin en Yvelines, France.
authors.forename: Raphaël
authors.initials: R
authors.lastname: Coscas
authors.affiliation: Service de Chirurgie Vasculaire, Hôpital Universitaire Ambroise Paré, Boulogne-Billancourt, et Faculté de Médecine Paris-Ile de France-Ouest, Université de Versailles Saint Quentin en Yvelines, France.
authors.forename: Thibault
authors.initials: T
authors.lastname: Maumias
authors.affiliation: Service de Chirurgie Vasculaire, Hôpital Universitaire Ambroise Paré, Boulogne-Billancourt, et Faculté de Médecine Paris-Ile de France-Ouest, Université de Versailles Saint Quentin en Yvelines, France.
authors.forename: Clément
authors.initials: C
authors.lastname: Capdevila
authors.affiliation: Service de Chirurgie Vasculaire, Hôpital Universitaire Ambroise Paré, Boulogne-Billancourt, et Faculté de Médecine Paris-Ile de France-Ouest, Université de Versailles Saint Quentin en Yvelines, France.
authors.forename: Isabelle
authors.initials: I
authors.lastname: Javerliat
authors.affiliation: Service de Chirurgie Vasculaire, Hôpital Universitaire Ambroise Paré, Boulogne-Billancourt, et Faculté de Médecine Paris-Ile de France-Ouest, Université de Versailles Saint Quentin en Yvelines, France.
authors.forename: Olivier
authors.initials: O
authors.lastname: Goëau-Brissonnière
authors.affiliation: Service de Chirurgie Vasculaire, Hôpital Universitaire Ambroise Paré, Boulogne-Billancourt, et Faculté de Médecine Paris-Ile de France-Ouest, Université de Versailles Saint Quentin en Yvelines, France. Electronic address: mpcoggia@aol.com.
authors.forename: Marc
authors.initials: M
authors.lastname: Coggia
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D017544:Aortic Aneurysm, Abdominal / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D001027:Aortography / Q000379:methods; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000401:mortality; D057510:Endovascular Procedures / Q000009:adverse effects / Q000401:mortality; D005260:Female; D006801:Humans; D010535:Laparoscopy / Q000009:adverse effects / Q000401:mortality; D008017:Life Expectancy; D008297:Male; D008875:Middle Aged; D057240:Patient Preference; D018579:Patient Selection; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome