title: The impact of stent graft evolution on the results of endovascular abdominal aortic aneurysm repair.
abstract: OBJECTIVE
  There have been four eras in the development of endovascular aneurysm repair (EVAR): physician-made grafts, early industry devices, intermediary commercial endografts, and modern stent grafts. This study analyzes differences in outcomes between these four groups and the impact of device evolution and increased physician experience.
  
  
  METHODS
  From 1992 to 2012, 1380 patients underwent elective EVAR. Fourteen different devices were used during this time. The four generations were defined as follows: era 1, all physician-made devices; era 2, June 1994 to June 2003; era 3, June 2003 to January 2008; and era 4, January 2008 to July 2012. Grafts used in each era were the following: era 1, physician made; era 2, early industry, such as EVT, Talent, AneuRx, Excluder, Quantum LP, Vanguard, Ancure, and Teramed; era 3, Talent, Endologix, Excluder, AAAdvantage, Zenith, and Aptus; and era 4, Zenith, Endurant, and Excluder.
  
  
  RESULTS
  Mean age was 75.2 years, and 84.5% were men. Adjunctive procedures decreased from era 1 to era 2 (P < .001) but rose again in eras 3 and 4 (P < .001). Procedure times (P < .001), blood loss (P < .001), and length of stay (P < .001) have decreased in eras 2, 3, and 4 compared with era 1. Major perioperative complications (era 1, 23%; era 2, 5.9%; era 3, 4.9%; and era 4, 4.7%; P < .001), abdominal aortic aneurysm-related perioperative mortality (era 1, 4.3%; era 2, 0.2%; era 3, 0.06%; and era 4, 0.5%; P < .001), and all-cause perioperative mortality (era 1, 7.7%; era 2, 1.9%; era 3, 1.5%; and era 4, 0.47%; P < .001) have also decreased in eras 2, 3, and 4 compared with era 1. Type I and type III endoleaks (P < .001) and the need for reintervention (P < .001) have decreased. Freedom from aneurysm-related mortality has significantly improved.
  
  
  CONCLUSIONS
  EVAR has evolved during the last 20 years, resulting in an improvement in efficiency, outcomes, and procedural success. The most significant advance is seen in the transition from era 1 to the later eras.
authors.affiliation: Division of Vascular Surgery, Department of Surgery, The Ichan School of Medicine at Mount Sinai, New York, NY. Electronic address: rami.tadros@mssm.edu.
authors.forename: Rami O
authors.initials: RO
authors.lastname: Tadros
authors.affiliation: Division of Vascular Surgery, Department of Surgery, The Ichan School of Medicine at Mount Sinai, New York, NY.
authors.forename: Peter L
authors.initials: PL
authors.lastname: Faries
authors.affiliation: Division of Vascular Surgery, Department of Surgery, The Ichan School of Medicine at Mount Sinai, New York, NY.
authors.forename: Sharif H
authors.initials: SH
authors.lastname: Ellozy
authors.affiliation: Division of Vascular Surgery, Department of Surgery, The Ichan School of Medicine at Mount Sinai, New York, NY.
authors.forename: Robert A
authors.initials: RA
authors.lastname: Lookstein
authors.affiliation: Division of Vascular Surgery, Department of Surgery, The Ichan School of Medicine at Mount Sinai, New York, NY.
authors.forename: Ageliki G
authors.initials: AG
authors.lastname: Vouyouka
authors.affiliation: Division of Vascular Surgery, Department of Surgery, The Ichan School of Medicine at Mount Sinai, New York, NY.
authors.forename: Rachel
authors.initials: R
authors.lastname: Schrier
authors.affiliation: Division of Vascular Surgery, Department of Surgery, The Ichan School of Medicine at Mount Sinai, New York, NY.
authors.forename: Jamie
authors.initials: J
authors.lastname: Kim
authors.affiliation: Division of Vascular Surgery, Department of Surgery, The Ichan School of Medicine at Mount Sinai, New York, NY.
authors.forename: Michael L
authors.initials: ML
authors.lastname: Marin
mesh_terms: D000368:Aged; D017544:Aortic Aneurysm, Abdominal / Q000401:mortality / Q000601:surgery*; D001807:Blood Vessel Prosthesis / Q000592:standards*; D017558:Elective Surgical Procedures; D057867:Endoleak / Q000453:epidemiology*; D057510:Endovascular Procedures / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D015994:Incidence; D007902:Length of Stay / Q000639:trends; D008297:Male; D009518:New York / Q000453:epidemiology; D011379:Prognosis; D011474:Prosthesis Design; D011475:Prosthesis Failure; D012086:Reoperation; D012189:Retrospective Studies; D015607:Stents / Q000592:standards*