Should patients with challenging anatomy be offered endovascular aneurysm repair?

Treatment of abdominal aortic aneurysm is controversial in patients at high physiologic risk for open repair and high anatomic risk for endovascular repair. We compared outcome in patients at high risk because of anatomy (short or angulated neck), severe occlusive disease, or bilateral iliac aneurysms (group A) with outcome in patients at low risk (group B).

Patients at high anatomic risk who underwent treatment between October 1998 and March 2002 with the Zenith endovascular graft (group A) were compared with patients at low anatomic risk enrolled in a prospective multicenter trial (group B). Variables compared included overall mortality, need for secondary interventions, development of endoleak, and change in aneurysm sac diameter. The chi(2) test, Student t test, and proportions analysis were used to assess the data.

Data for 493 patients (group A, 141; group B, 352) were evaluated. Mean follow-up was 9 months (range, 1-24 months). Perioperative mortality was similar for groups A and B (0.7% vs 1%). Frequency of endoleak was higher in patients with high-risk anatomy (25% vs 11%), but not significantly so (P >.06). The rate of aneurysm shrinkage, even in the absence of endoleak, was slower in group A (P <.05).

In physiologically challenged patients at higher anatomic risk for endovascular aneurysm repair, initial mortality rate is similar to that in patients at lower risk. Short-term technical results are acceptable. Decreased long-term survival (largely unrelated to the procedure), slightly higher frequency of endoleak, and a lower rate of sac shrinkage may temper enthusiasm for endovascular repair in this subgroup. Risks of repairing aneurysms in this patient population must be viewed in the context of expected results of intervention or medical observation.