[Endoprostheses for aneurysms of the abdominal aorta. A technical innovation, a cultural revolution]

A revolutionary technology has totally renovated the treatment of aneurysms of the abdominal aorta. Classical "dissection-graft" procedures require a wide abdominal incision with clamping and declamping times, and often major blood loss. Perioperative mortality varies from 3% to 7% depending on the team's experience and the presence of comorbidities. Complications occur in 30% of the patients; often benign they can be quite serious. As direct consequence of the development of peripheral stents, endoprostheses can now be introduced via the femoral route through a short inguinal incision. Operative trauma is considerably reduced, greatly shortening the recovery time. Mortality is low, of around 1%, and postoperative complications are much less frequent and much less severe. There is also a 3-fold reduction in the duration of the hospital stay.

All aneurysms cannot be treated with this method. The anatomy of the aneurysm and the iliac arteries is a determining factor. The iliac vessels must be large enough and devoid of important obstruction (kinks, atheromatous plaques) in order to access the aorta. The subrenal collar must measure at least 1 cm and be free of severe calcifications or thrombi. A rigorous preoperative exploration, using CT-scan with 3D reconstruction and graduated arteriography, is necessary. The length and diameter of the prosthesis is calculated from the results and must be perfectly adapted to avoid failure.

Long-term outcome remains unknown. The endoprosthesis excluded the aneurysm from the blood stream, depressurizing the aneurysmal sac. Endoprosthetic leakage can occur in case of defective application or by reflux from lumbar or inferior mesenteric arteries or due to leakage of the endoprosthesis itself. In such cases, the aneurysm can continue to progress. This explains the need for careful follow-up with duplex Doppler and/or CT-scan in treated patients. If the treatment is incomplete, complementary procedures may be necessary, often via an endovascular route or in some cases with conversion to conventional surgery.

Improved prosthetic design and durability is an important point. Randomized studies organized in France, as well as in England and Holland and the United States, are currently assessing the contribution of this new technique and its relative role compared with conventional surgery.